Error processing SSI file
Glossary of Terms
This glossary is available to give you general information about words and terms associated with aging, disability or long-term care. Many sources have been used to compile this list, and there may be more than one "definition" for a word/term. To find a term, select the first letter of the word/term you are seeking. A list of acronyms is also available (links are available throughout this page). If you would like to suggest new items to add, email us at webmaster.DALTCP@hhs.gov.
An individual's ability to obtain appropriate health care services. Barriers to access can be financial, geographic, organizational and sociological. Efforts to improve access often focus on providing/improving health coverage.
As required by the Americans with Disabilities Act, removal of barriers that would hinder a person with a disability from entering, functioning, and working within a facility. Required restructuring of the facility cannot cause undue hardship for the employer.
A process whereby a program of study or an institution is recognized by an external body as meeting certain predetermined standards. For facilities, accreditation standards are usually defined in terms of physical plant, governing body, administration, and medical and other staff. Accreditation is often carried out by organizations created for the purpose of assuring the public of the quality of the accredited institution or program. The state or federal governments can recognize accreditation in lieu of, or as the basis for licensure or other mandatory approvals. Public or private payment programs often require accreditation as a condition of payment for covered services. Accreditation may either be permanent or may be given for a specified period of time.
An error that occurs at the level of the front line operator and whose effects are felt almost immediately.
Activities of Daily Living (ADLs)
Basic personal activities which include bathing, eating, dressing, mobility, transferring from bed to chair, and using the toilet. ADLs are used to measure how dependent a person may be on requiring assistance in performing any or all of these activities.
Care that is generally provided for a short period of time to treat a certain illness or condition. This type of care can include short-term hospital stays, doctor's visits, surgery, and X-rays.
Medical treatment rendered to individuals whose illnesses or health problems are of a short-term or episodic nature. Acute care facilities are those hospitals that mainly serve persons with short-term health problems.
A disease that is characterized by a single episode of a relatively short duration from which the patient returns to his/her normal or previous level of activity. While acute diseases are frequently distinguished form chronic diseases, there is no standard definition or distinction.
Illness that is usually short-term and that often comes on quickly.
Adjusted Average Per Capita Cost (AAPCC)
The basis for HMO or CMP reimbursement under Medicare-risk contracts. The average monthly amount received per enrollee is currently calculated as 95% of the average costs to deliver medical care in the fee-for-service sector.
Administrative Services Organization (ASO)
An entity that contracts with a state or other purchaser to provider designated administrative services, such as billing or utilization tracking.
Date at which an individual was reported to have been admitted to a nursing home for which a Medicaid claim has been paid. Admission may occur before the beginning of a Medicaid-financed nursing home spell if a person entered the nursing home with other insurance coverage before Medicaid began covering the nursing facility care.
(Also called regulated insurance carriers.) Commercial insurers whose nursing home liability insurance products are regulated by state departments of insurance. These carriers enjoy some advantages over non-admitted carries. They can participate in state guaranty funds, which help protect policyholders in the case of insurer insolvency. Also, they have a marketing advantage over non-admitted carriers because some brokers, facility providers and lenders value state oversight and participation in the guaranty fund.
Adult Care Home
(Also called board and care home or group home.) Residence which offers housing and personal care services for 3 to 16 residents. Services (such as meals, supervision, and transportation) are usually provided by the owner or manager. May be single family home. (Licensed as adult family home or adult group home.)
Adult Day Care
A daytime community-based program for functionally impaired adults that provides a variety of health, social, and related support services in a protective setting.
Advance Care Planning
The process of discussing, determining and/or executing treatment directives and appointing a proxy decision maker.
Advance Health Care Directive
(Also called advance directive.) A written instructional health care directive and/or appointment of an agency, or a written refusal to appoint an agent or execute a directive.
Adverse Drug Reaction (ADR)
An undesirable response associated with use of a drug that compromises therapeutic efficacy., enhances toxicity, or both.
In a medical context, an injury resulting from a medical intervention.
A tendency for utilization of health services in a population group to be higher than average. From an insurance perspective, adverse selection occurs when persons with poorer-than-average health status apply for, or continue, insurance coverage to a greater extent than do persons with average or better health expectations.
Age Discrimination in Employment Act (ADEA)
A 1967 federal law that prohibits employers with 20 or more employees from discriminating on the basis of age in hiring, job retention, compensation, and benefits. ADEA also sets requirements for the duration of employer-provided disability benefits.
An individual designated in a legal document known as a power of attorney for health care to make a health care decision for the individual granting the power; also referred to in statute as durable power of attorney for health care, attorney in fact, or health care representative.
Alcohol, Drug Abuse and Mental Health Services Block Grant
There are no Federal requirements. States have discretion over who is served. However, services are to be targeted to individuals with chronic mental illness, severely mentally disturbed children and adolescents, mentally ill elderly individuals and other identifiable populations which are underserved.
Allied Health Personnel
Specially trained and licensed health workers other than physicians, dentists, optometrists, chiropractors, podiatrists, and nurses. The term has no constant or agreed-upon detailed meaning; it is sometimes used synonymously with paramedical personnel, sometimes meaning all health workers who perform tasks that must otherwise be performed by a physician, and at other times referring to health workers who do not usually engage in independent practice.
All Patient Diagnosis Related Group (APDRG)
An enhancement of the original DRGs, designed to apply to a population broader than that of Medicare beneficiaries, who are predominately older individuals. the APDRG set includes groupings for pediatric and maternity cases as well as of services for HIV-related conditions and other special cases.
A system in which prices for health services and payment methods are the same, regardless of who is paying. For instance, in an all-payer system, federal or state government, a private insurer, a self-insured employer plan, an individual, or any other payer could pay the same rates. The uniform fee bars health care providers from shifting costs from one payer to another. See cost shifting.
Items or elements of an institution's costs that are reimbursable under a payment formula. Both Medicare and Medicaid reimburse hospitals on the basis of only certain costs. Allowable costs may exclude, for example, luxury accommodations, costs that are not reasonable expenditures, or that are unnecessary for the efficient delivery of health services to persons covered under the program in question.
The Alternative Market to nursing home liability insurance is composed of various forms of self-insurance, meaning the risk os borne by the participants and not an insurance company. The different forms of self-insurance include risk retention and risk purchasing groups, captives, rent-a-captives, and sponsored captives.
A progressive, irreversible disease characterized by degeneration of the brain cells and serve loss of memory, causing the individual to become dysfunctional and dependent upon others for basic living needs.
All types of health services which are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients. While many inpatients may be ambulatory, the term ambulatory care usually implies that the patient must travel to a location to receive services which do not require an overnight stay. Also see ambulatory setting and outpatient.
Ambulatory Payment Classification (APC)
The basis for payment for care in the Outpatient Prospective Payment System. The APC is used in a fashion similar to the way DRGs are used for payment for inpatients. Both APCs and DRGs are intended to represent groups of patients that are similar clinically and that also have roughly the same resource consumption. The significant difference between them is that APCs depend on the procedures perfoemed whereas DRGs depend on the diagnosis treated.
A type of institutional organized health setting in which health services are provided on an outpatient basis. Ambulatory care settings may be either mobile or fixed.
Americans with Disabilities Act (ADA):
An individual must meet one of the following three tests: (a) have a physical or mental impairment that substantially limits one or more of the major life activities of such individual; (b) have a record of such an impairment; or (c) be regarded as having an impairment. (Same as Section 504 of the Rehabilitation Act of 1973 and the Fair Housing Amendments of 1988.)
Supplemental services, including laboratory, radiology, physical therapy, and inhalation therapy, that are provided in conjunction with medical or hospital care.
An error reporting method used to protect the identity of those individuals who report medical errors so that their reports cannot be easily used in civil lawsuits against them. Under anonymous reporting, data that could identify the reporter are omitted from the report. See de-identification.
A legal term encompassing a variety of efforts on the part of government to ensure that sellers do not conspire to restrain trade or fix prices for their goods or services in the market.
Any Willing Provider Laws
Laws that require managed care plans to contract with all health care providers that meet their terms and conditions.
Appropriate health care is care for which the expected health benefit exceeds the expected negative consequences by a wide enough margin to justify treatment.
Contracts, the terms of which are determined by an arbitrator, entered into by opposing parties. An arbitrator is a person or panel of people who are not judges and may be: (1) agreed to by the parties; (2) required by a provision in a contract for settling disputes; or (3) provided for under statute. Arbitration is designed to be a fair and equitable means of dispute resolution agreed to by both parties to avoid a court trial and the associated expenses and time investment.
Area Agency on Aging (AAA)
A local (city or county) agency, funded under the federal Older Americans Act, that plans and coordinates various social and health service programs for persons 60 years of age or more. The network of AAA offices consists of more than 600 approved agencies.
Area Health Education Center (AHEC)
An organization or organized system of health and educaitonal institutions whose purpose is to improve the supply, distribution, quality, use, and efficiency of health care personnel in specific medically underserved areas. An AHEC's objectives are to educate and train the health personnel specifically needed by the underserved areas and to decentralize health workforce education, thereby increasing supply and linking the health and educaitonal institutions in scarcity areas.
Artificial Nutrition and Hydration
(Also known as tube feeding.) Artificial nutrition and hydration supplements or replaces ordinary eating and drinking by giving nutrients and fluids through a tube placed directly into the stomach (gastrostomy tube or G-tube), the upper intestine, or a vein.
A process in which a Medicare beneficiary agrees to have Medicare's share of the cost of a service paid directly ("assigned") to a doctor or other provider, and the provider agrees to accept the Medicare approved charge as payment in full. Medicare pays 80% of the cost and the beneficiary 20%, for most services. See participating physician.
Residences that provide a "home with services" and that emphasize residents' privacy and choice. Residents typically have private locking rooms (only shared by choice) and bathrooms. Personal care services are available on a 24-hour-a-day basis. (Licensed as residential care facilities or as rest homes.)
A broad range of residential care services that includes some assistance with activities of daily living and instrumental activities of daily living, but does not include nursing services such as administration of medication. Assisted living facilities and in-home assisted living care stress independence and generally provide less intensive care than that delivered in nursing homes and other long-term care institutions.
Assisted Living Facility (ALF) Benefit Amount
The maximum amount which the policy or certificate will pay for care received in an ALF. If the benefit is paid as weekly or monthly, the daily amount should be derived by whatever convention is most appropriate for the carrier to use. The data should be the current amount on the policy in order to account both for any voluntary increases in coverage the insured has elected or any automatic coverage increases as a result of inflation protection.
Assisted Living/Other Facility Benefits Paid During Reporting Period
The total dollar amount of benefits paid during the reporting period for care provided in an ALF or similar alternate care facility other than a nursing home.
Tools that enable individuals with disabilities to perform essential job functions, e.g., telephone headsets, adapted computer keyboards, enhanced computer monitors.
Automatic Inflation Protection Type
The type of inflation protection used in the policy. This includes automatic inflation protection on a compound, level-funded basis; or a simple increase and level-funded basis; a graded inflation protection feature where both the premium and the benefit amounts increase at a known and pre-set amount each year; step-rated inflation protection; level-funded increases based on the Consumer Price Index; level-funded increases based on the specific long-term care price index; level-funded inflation protection based on some other published index value; level-funded inflation protection based on an increase amount determined by the carrier which could change from year to year based on the changes in actual costs of care. All these types of inflation protection are provided annually and continue on claim (unless other predefined limits are reached first).
Average Wholesale Price (AWP) of Prescription Drugs
The average wholesale price of a drug relates to the price that wholesalers charge pharmacies, and is often used by pharmacists to price prescriptions. Drug manufacturers and labelers commonly publish suggested wholesale prices for their products. Price surveys of wholesalers are also available.
Avoidable Hospital Conditions
Medical diagnosis for which hospitalization could have been avoided if ambulatory care had been provided in a timely and efficient manner.
Income lost to a provider because of failure of patients to pay amounts owed. Bad debts may sometimes be recovered by increasing charges to paying patients. Some cost-based reimbursement programs reimburse certain bad debts. The impact of the loss of revenue from bad debts may be partially offset for proprietary institutions by the fact that income tax is not payable on income not received.
In Medicare and private fee-for-service health insurance, the practice of billing patients for charges that exceed the amount that the health plan will pay. Under Medicare, the excess amount cannot be more than 15% above the approved charge. See approved charge and participating physician.
Basis of Eligibility (BOE)
Eligibility group that traditionally has been used by CMS to classify enrollees as children, adults, aged, or disabled.
An umbrella term that includes mental health and substance abuse, and frequently is used to distinguish from "physical" health. Health care services provided for depression or alcoholism would be considered behavioral health care, while setting a broken leg would be physical health. See parity.
Behavioral Risk Factor Surveillance System (BRFSS)
The BRFSS, the world's largest telephone survey, tracks risk behaviors related to chronic diseases, injuries, and death in the United States. Administered and supported by the Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, the BRFSS is an ongoing data collection program. By 1994, all states, the District of Columbia, and three territories were participating in the BRFSS.
A level of care set as a goal to be attained. Internal benchmarks are derived from similar processes or services within an organization. Competitive benchmarks are comparisons with the best external competitors in the field. Generic benchmarks are drawn drom the best performance of similar processes in other industries.
An individual who receives benefits from or is covered by an insurance policy or other health care financing program.
Benefit Start Date of Current Claim Period
The date on which benefit payments began during the reporting period.
The difference between the sample statistic and the population statistic caused by factors other than random error. If a sample statistic is biased, then repeating the survey many times would produce a distribution of sample statistics that would be centered around something other than the population value for the statistic. Thus, a biased sample statistic would have a tendency to be either too small or too large as an estimate of the population statistic. One common source of bias in all surveys occurs when the nonrespondents have different characteristics from the respondents.
The market imperfection that results from the uneven grouping of risks among competing subscribers. Biased selection includes favorable selection (attracting good risks and repelling bad ones) as well as adverse selection (the reverse). Biased selection can occur naturally, according to historical or accidental patterns, or it can occur strategically, according to conscious choices by either subscribers or insurers.
The unlawful use, or threatened use, of micro-organisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants. The act is intended to create fear and/or intimidate governments or societies in the pursuit of political, religious, or ideological goals.
Black Lung (Pneumoconiosis)
Pneumoconiosis is a disease of the lungs caused by the habitual inhalation of irritant mineral or metallic particles. A miner must meet three general conditions: (1) must have (or, if deceased, have had) pneumoconiosis; (2) be totally disabled by the disease (or have been totally disabled at the time of death); and (3) the pneumoconiosis must have arisen out of coal mine employment. Dependent coverage is also provided to widows of miners who died of Black Lung disease and to their dependents.
The process of integrating funds from different sources (e.g., Medicaid and block grant monies) to enhance flexibility in supporting an individualized set of services for designated patients.
Board and Care Home
(Also called adult care home or group home.) Residence which offers housing and personal care services for 3 to 16 residents. Services (such as meals, supervision, and transportation) are usually provided by the owner or manager. May be single family home. (Licensed as adult family home or adult group home.)
Status granted a medical specialist who completes a required course of training and experience (residency) and passes an examination in his/her specialty. Individuals who have met all requirements except examination are referred to as "board eligible".
Part of the Medicaid law, known by the name of its principal Congressional sponsor. It provides that state payment for hospitals and nursing facilities must be reasonable and adquate to meet the costs incurred by efficiently and economically operated facilities to provide care and services meeting state and federal standards.
The process of combining funds from different sources to support an individualized set of services so that expenditures from each source can be tracked and applied to specific individuals eligible for that funding.
Buy-up Option Available
Indicates that, in addition to an employer paid core plan, insureds can elect to purchase on their own additional coverage amounts and types, typically subject to some form of underwriting.
Cafeteria Benefits Plan
An arrangement under which employees may choose their own benefit struction, allowing employees to tailor their benefits package to best meet their specific needs. For example, an employee with no dependents may forgo life insurance but may prefer more comprehensive health insurance package.
An individual's ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. The term is frequently used interchangeably with compentency but is not the same. Competency is a legal status imposed by the court.
Fixed or durable non-labor inputs or factors used in the production of goods and services, the value of such factors, or the money specifically allocated for their acquisition or development. Capital costs include, for example, the buildings, beds, and equipment used in the provision of hospital services. Capital assets are usually thought of as permanent and durable as distinguished from consumables such as supplies.
Capital Expenditure Review
A review of proposed capital expenditures of hospitals and/or other health facilities to determine the need for, and appropriateness of, the proposed expenditures. The review is done by a designated regulatory agency and has a sanction attached that prevents or discourages unneeded expenditures.
Funding that reserves of an insurance or self-insurance program to pay claims.
A method of payment for health services in which the provider is paid a fixed amount for each patient without regard to the actual number or nature of services provided. Capitation payments are charactistic of health maintenance organizations (HMOs). Also, a method of public support of health professional schools in which eligible schools receive a fixed grant for each student enrolled.
A fixed amount of money paid per person for covered services for a specific time; usually expressed in "per member per month" units.
A self-formed pool of providers who share risk among themselves, thus acting as their own insurance company. Members do their own underwriting, meaning they decide among themselves which providers to admit to the captive. Members will share liability risk with the providers they admit.
Cardiopulmonary Resuscitation (CPR)
A group of treatments used when someone's heart and/or breathing stops. CPR is used in an attempt to restart the heart and breathing. It usualy consists of mouth-to-mouth breathing and pressing on the chest to cause blood to circulate. Electric shock and drugs also are used to restart or control the rhythm of the heart.
(Also called service plan or treatment plan.) Written document which outlines the types and frequency of the long-term care services that a consumer receives. It may include treatment goals for him or her for a specified time period.
Person who provides support and assistance with various activities to a family member, friend, or neighbor. May provide emotional or financial support, as well as hands-on help with different tasks. Caregiving may also be done from long distance.
Offers a single point of entry to the aging services network. Care/case management assess clients' needs, create service plans, and coordinate and monitor services; they may operate privately or may be employed by social service agencies or public programs. Typically case managers are nurses or social workers.
The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services.
Procedures and processes used by trained service providers or a designated entity to assist children and families in accessing and coordinating services.
A private organization, usually an insurance company, that finances health care.
Regarding health insurance, an arrangement whereby an employer eliminates coverage for a specific category of services (e.g., vision care, mental health/psychological services, and prescription drugs) and contracts with a separate set of providers for those services according to a predetermined fee schedule or capitation arrangement. Carve out may also refer to a method of coordinating dual coverage for an individual.
Refers to a single patient or case.
A method by which a health care provider measures the service needs of the patient population, and may be based on age, medical diagnosis, severity of illness, or length of stay. A nursing home or hospital's actual case mix influences cost and scope of the services provided by the facility to the patient, and case mix reimbursement systems adjust payment rates accordingly.
A measure of the mix of cases being treated by a particular health care provider that is intended to reflect the patients' different needs for resources. Case mix is generally established by estimating the relative frequency of various types of patients seen by the provider in question during a given time period and may be measured by factors such as diagnosis, severity of illness, utilization of services, and provider characteristics.
A fixed amount of money paid per person to allow a provider or designated entity to pay for covered services needed by that person; rates are typically based on diagnoses of persons who present for services and expressed as monthly amounts.
A measure of intensity or gravity of a given condition or diagnosis for a patient.
Catastrophic Health Insurance
Health insurance that provides protection against the high cost of treating severe or lengthy illnesses or disability. Generally such policies cover all, or a specified percentage of, medical expenses above an amount that is the responsibility of another insurance policy up to a maximum limit of liability.
A geographic area defined and served by a health program or institution such as a hospital or community mental health center that is delineated on the basis of such factors as population distribution, natural geographic boundaries, and transportation accessibility. By definition, all residents of the area needing the services of the program are usually eligible for them, although eligibility may also depend on additional criteria.
Persons whose Medicaid eligibility is based on their family, age or disability status. Persons not falling into these categories cannot qualify, no matter how low their income. The Medicaid statute defines over 50 distinct population groups as potentially eligible, including those for which coverage is mandatory in all states and those that may be covered at a state's option. The scope of covered services that states provide to the categorially needy is much broader than the minimum scope of services for the other, optional groups receiving Medicaid benefits. See medically needy.
A captive in which member providers share administrative expenses but not risk.
Certificate Issue State
The state in which a certificate under a group policy is delivered. This would be either the situs state for the group policy or, in the case of a state that claims extraterritorial jurisdiction over the group policy situs state, it would be the state of residence for the individual certificate-holder.
Certificate of Need (CON)
A certificate issued by a government body to a health care provider who is proposing to construct, modify, or expand facilities, or to offer new or different types of health services. CON is intended to prevent duplication of services and overbedding. The certificate signifies that the change has been approved.
The process by which a governmental or non-governmental agency or association evaluates and recognizes an individual, institution, or educational program as meeting predetermined standards. One so recognized is said to be "certified." It is essentially synonymous with accreditation, except that certification is usually applied to individuals, and accreditation to institutions. Certification programs are generally non-governmental and do not exclude the uncertified from practice as do licensure programs.
Certified Nurse Aide (CNA)
A nurse aide that has completed required state training and competency testing in the skills required to work as a nurse aide.
Generally refers to physician and hospital services provided to persons who are unable to pay for the cost of services, especially those who are low-income, uninsured, and underinsured. A high proportion of the costs of charity care is derived from services for children and pregnant women (e.g., neonatal intensive care).
Help with chores such as home repairs, yard work, and heavy housecleaning.
Care and treatment given to individuals whose health problems are of a long-term and continuing nature. Rehabilitation facilities, nursing homes, and mental hospitals may be considered chronic care facilities.
A disease that has one or more of the following characteristics: is permanent; leaves residual disability; is caused by nonreversible pathological alternation; requires special training of the patient for rehabilitation; or may be expected to require a long period of supervision, observation, or care.
Long-term or permanent illness (e.g., diabetes, arthritis) which often results in some type of disability and which may require a person to seek help with various activities.
A patient has been certified by a licensed health care pratitioner as: being unable to perform, without substantial assistance from another person, at least two ADLs for a period that is expected to last at least 90 consecutive days due to a loss of functional capacity; or requiring substantial supervision to protect themself form threats to health and safety due to a severe cognitive impairment.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
A Department of Defense program supporting private sector care for military dependents. See TRICARE.
Program for the Handicapped (PFTH). Disability for military dependents is based on the strength and duration of a physical or mental handicap. The physical handicap must be of such severity as to preclude the individual from performing basic activities of daily living at a level expected of unimpaired individuals of the same age group and must be expected to result in death or to have lasted or be expected to last for at least 12 months. For a mental handicap, the applicant must be medically determined to be moderately or severely retarded.
Indicates whether or not an insured with a Partnership policy is in claim status during the reporting period.
Claims Made Policy
Provides coverage for insured events that both occur and for which a claim is made during the term of the policy. If an incident occurs, but the policy is terminated before a claim is made, liability for the incident is not insured.
Claims Occurrence Policy
Provides coverage for all incidents and events that occur during the term of the policy, regardless of when a liability claim is made, or when a lawsuit is settled.
A facility, or part of one, devoted to diagnosis and treatment of outpatients. "Clinic" is irregularly defined. It may either include or exclude physicians' offices; may be limited to describing facilities that serve poor or public patients; and may be limited to facilities in which graduate or undergraduate medical education is done.
A diagnosis (e.g., cerebrovascular hemorrhage) or a patient state that may be associated with more than one diagnosis (such as paraplegia) or that may be as yet undiagnosed (such as low back pain).
Services provided to patients (items of history taking, physical examination, preventative care, tests, procedures, drugs, advice) or information on clinical condition or on patient state used as a patient outcome.
Clinical Performance Measures
Instruments that estimate that extent to which a health care provider: delivers clinical services that are appropriate for each patient's condition; provides them safely, competently, and in an appropriate time frame; and achieves desired outcomes in terms of those aspects of patient health and patient satisfaction that can be affected by clinical services.
Clinical Practice Guidelines
Systematically developed statements to assist practitioners and patients' decisions about health care to be provided for specific clinical circumstances.
A naturally occurring unit like a school (which has many classrooms, students, and teachers). Other clusters include universities, hospitals, cities, states, Census blocks, and living quarters. The clusters are randomly selected, and all members, or a random sample, of the selected cluser are included in the sample.
(Also called co-payment.) The specified portion (dollar amount or percentage) that Medicare, health insurance, or a service program may require a person to pay toward his or her medical bills or services.
A cost-sharing requirement under a health insurance policy. It provides that the insured party will assume a portion or percentage of the costs of covered services. The health insurance policy provides that the insurer will reimburse a specified percentage of all, or certain specified, covered medical expenses in excess of any deductible amounts payable by the insured. The insured is then liable for the remainder of the costs until their maximum liability is reached.
Condition that exists at the same time as the primary condition in the same patient (e.g., hypertension is a co-morbidity of many conditions such as diabetes, ischemic heart disease, end-stage renal disease, etc.).
(Also called co-insurance.) The specified portion (dollar amount or percentage) that Medicare, health insurance, or a service program may require a person to pay toward his or her medical bills or services.
A fixed amount of money paid by a health plan enrollee (beneficiary) at the time of service. For example, the enrollee may pay a $10 "co-pay" at every physician office visit, and $5 for each drug prescription filled. The health plan pays the remainder of the charge directly to the provider. This is a method of cost-sharing between the enrollee and the plan, and serves as an incentive for the enrollee to use healthcare resources wisely. An enrollee might be offered a lower price benefit package in return for a higher co-payment.
Coefficient of Variation
The standard error of an estimate divided by the mean.
Deterioration or loss of intellectual capacity which requires continual supervision to protect the insured or others, as measured by clinical evidence and standardized tests that reliably measure impairment in the area of (1) short or long-term memory, (2) orientation as to person, place and time, or (3) deductive or abstract reasoning. Such loss in intellectual capacity can result from Alzheimer's disease or similar forms of senility or Irreversible Dementia.
Damages incurred by the plaintiff that are already covered by other sources of payment. "Collateral source offset" rules reduce awards by denying plaintiffs compensation for losses that are recouped from other sources such as health insurance. These rules aim to prevent plaintiffs from "double dipping" by recovering for losses for which the plaintiff has already been remunerated through other sources of payment.
Community Health Center
(Also called neighborhood health center.) An ambulatory health care program usually serving a catchment area which has scarce or nonexistent health services or a population with special health needs. These centers attempt to coordinate federal, state, and local resources in a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient population.
Community Health Center (CHC)
An ambulatory health care program (defined under Section 330 of the Public Health Service Act) usually serving a catchment area that has scarce or nonexistent health services or a population with special health needs. Sometimes known as "neighborhood health center." CHCs attempt to coordinate federal, state, and local resources in a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all health care services needed by its patient population.
Community Long-Term Care (CLTC)
Services covered under 1915(c) waivers and personal care, residential care, home health, adult day, and private duty nursing services provided at state option. Because unduplicated measures of community long-term care waiver use and service-specific use are not available in MAX PS files, CLTC is operationally defined as services covered under waivers for people receiving waiver services, and use of personal care, residential care, home health, adult day, and private duty nursing for all other enrollees.
Community Mental Health Center (CMHC)
An entity that provides comprehensive mental health services (principally ambulatory), primarily to individuals residing or employed in a defined catchment area.
A method of calculating health plan premiums using the average cost of actual or anticipated health services for all subscribers within a specific geographic area. The premium does not vary for different groups or subgroups of subscribers to reflect their specific claims experience or health status. Under modified community rating (the most common form), rates may vary based on subscribers' specific demographic characteristics (such as age and gender), but rate variation based on individuals' health status, claims experience, or policy duration is prohibited. "Pure" community rating prohibits rate variation based on demographic as well as health factors, and all subscribers in an area pay the same rate.
Community Rating by Class (CRC or Class Rating)
For federally qualified HMOs, the CRC is the adjustment of community-rated premiums on the basis of such factors as age, sex, family size, marital status, and industry classification. These health plan premiums reflect the experience of all enrollees of a given class within a specific geographic area, rather than the experience of any one employer gorup.
Services designed to help older people remain independent and in their own homes; can include senior centers, transportation, delivered meals or congregate meals site, visiting nurses or home health aides, adult day care, and homemaker services.
The beld of health and social services provided to an individual or family in their place of residence for the purpose of promoting, maintaining, or restoring health or minimizing the effects of illness and disability.
The 5-digit code assigned by the National Association of Insurance Commissioners to each insurance company. For self-funded plans or the Federal Employees' Long Term Care Insurance Program (FLTCIP), a unique 5-digit code will be assigned for use in these reporting requirements.
Competitive Medical Plan (CMP)
A state-licensed entity, other than a federally qualified HMO, that signs a Medicare Risk Contract and agrees to assume financial risk for providing care to Medicare eligibles on a prospective, prepaid basis.
Use of an estimator that is a weighted average of two other estimators. Frequently a composite is constructed from a direct sample-based estimator and a model-based estimator.
Computerized Physician Order Entry (CPOE)
Electronic systems in which physicians enter and transmit medication orders as well as orders for radiology, lab work, and other ancillary services. Physician order entry systems help catch and prevent errors by checking physician orders against potential drug to drug interactions, normal dosages, and diagnostic or therapeutic guidelines. Physician order entry systems also prevent medical errors due to misreading of hand-written orders.
Conditions of Participation (COP)
Standards a facility or supplier of services, desiring to participate in the Medicare or Medicaid program, is required to meet. These conditions include meeting a statutory definition of the particular institution or facility, conforming with state and local laws and having an acceptable utilization review plan. Surveys to determine whether facilities meet conditions of participation are made by the appropriate state health agency.
A range of values used to predict the location of the true population parameter. The probability of the true parameter values falling within the intervals is specified.
Individual apartments in which residents may receive some services, such as a daily meal with other tenants. (Other services may be included as well.) Buildings usually have some common areas such as a dining room and lounge as well as additional safety measures such as emergency call buttons. May be rent-subsidized (known as Section 8 housing).
A person who purchases or receives goods or services for personal needs or use and not for resale.
Continuing Care Retirement Community (CCRC)
communities which offer multiple levels of care (independent living, assisted living, skilled nursing care) housed in different areas of the same community or campus and which give residents the opportunity to remain in the same community if their needs change. Provide residential services (meals, housekeeping, laundry), social and recreational services, health care services, personal care, and nursing care. Require payment of a monthly fee and possibly a large lump-sum entrance fee. (Licensed as nursing homes/residential care facilities or as homes for the aging.)
Continuing Medical Education (CME)
Formal education obtained by a health professional after completing his/her degree and full-time post-graduate training. For physicians, some states require CME (usually 50 hours per year) for continued licensure, as do some specialty boards for certification.
Continuum of Care
The entire spectrum of specialized health, rehabilitative, and residential services available to the frail and chronically ill. The services focus on the social, residential, rehabilitative and supportive needs of individuals as well as needs that are essentially medical in nature.
Clinical services provided during a single inpatient hospitalization or for multiple conditions over a lifetime. It provides a basis for evaluating quality, cost, and utilization over the long term.
A transaction where all or part of the assets of a health care organization undergo a shift in profit state (non-profit, public, or for-profit) through sale, lease, joint venture, or operating/management agreements.
Coordination of Benefits (COB)
Procedures used by insurers to avoid duplicate payment for losses insured under more than one insurance policy. A COB, or "nonduplication," clause in either policy prevents double payment by making one insurer the primary payer, and assuring that not more than 100% of the cost is covered. Standard rules determined which of two or more plans, each having COB provisions, pays its benefits in full and which becomes the supplementary payer on a claim.
An employer-paid long-term care insurance benefit provided typically on a guaranteed issue basis to all eligible actively at work employees as defined by the insurer and/or the employer in the group policy.
An accounting device whereby all related costs attributable to some "financial center" within an institution, such as a department or program, are segregated for accounting or reimbursement purposes.
Cost Consequence Analysis (CCA)
A form of cost-effectiveness analysis comparing alternative interventions or programs in which the components of incremental costs (e.g., additional therapies, hospitalization) and consequences (e.g., health outcomes, adverse effects) are computed and listed, without aggregating these results (e.g., into a cost-effectiveness ratio).
A set of steps to control or reduce inefficiencies in the consumption, allocation, or production of health care services which contribute to higher than necessary costs. Inefficiencies in consumption can occur when health services are inappropriately utilized; inefficiencies in allocation exist when health services could be delivered in less costly settings without loss of quality; and inefficiencies in production exist when the cost of producing health services could be reduced by using a different combination of resources.
Cost Minimization Analysis (CMA)
An assessment of the least costly intervention/technology among alternatives that produce equivalent outcomes.
(Also called Budget Neutrality.) Refers to the requirement that if a state applies for Medicaid waivers under sections 1115, 1915(b) and/or 1915(c), they must demonstrate that the program does not exceed what the Federal Government would have spent without approving the waiver; states can do this by showing that the average per capita expenditure estimated by the state in any fiscal year for medical assistance provided with respect to the group affected by the waiver does not exceed 100% of the average per capita expenditure that the state reasonably estimates would have been made in that fiscal year for expenditures under the state plan for such individuals if the waiver had not been granted.
Cost of Illness Analysis (COI)
An assessment of the economic impact of an illness or condition, including treatment costs.
Cost of Living Adjustment/Allowance (COLA)
Increase to a monthly long-term disability benefit, usually after the first year of payments. May be a flat percentage (e.g., 3%) or tied to changes in inflation. In some states, workers' compensation income replacement benefits also include annual COLAs.
Increase to an individual's salary or other benefit payment, usually after the first year of payments. May be a flat percentage (e.g., 3%) or tied to changes in inflation. For example, in some states, workers' compensation income replacement benefits or long-term disability benefits include annual COLAs.
Any provision of a health insurance policy that requires the insured individual to pay some portion of medical expenses. The general term includes deductibles, copayments, and coinsurance.
The practice of obtaining care for a child at the expense of another party or agency.
Cost Utility Analysis
A form of cost-effectiveness analysis were outcomes are rated in terms of utility, or quality of life, e.g., quality-adjusted life-years (QALYs).
Payment made by a health plan or payor to health care providers based on the actual costs incurred in the delivery of care and services to plan beneficiaries. This method of paying providers is still used by some plans; however, cost-based reimbursement is being replaced by prospective payment and other payment mechanisms.
An analytic method in which a program's cost is compared to the program's benefits for a period of time, expressed in dollars, as an aid in determining in best investment of resources. For example, the cost of establishing an immunization service might be compared with the total cost of medical care and lost productivity that will be eliminated as a result of more persons being immunized. Cost-benefit anlaysis can also be applied to specific medical tests and treatments.
Cost-Effectiveness Analysis (CEA)
A form of analysis that seeks to determine the costs and effectiveness of a medical intervention compared to similar alternative interventions to determine the relative degree to which they will obtain the desired health outcome(s). Cost-effectiveness analysis can be applied to any of a number of standards such as median life expectancy or quality of life following an intervention.
Recouping the cost of providing uncompensated care by increasing revenues from some payers to offset losses and lower net payments from other payers.
The guarantee against specific losses provided under the terms of an insurance policy. Coverage is sometimes used interchangeably with benefits or protection, and is also used to mean insurance or insurance contract.
Indicates whether the coverage is issued as a group or an individual policy. The coverage basis is determined by how the State Department of Insurance classifies the policy or certificate, not based on the basis by which the policy is marketed. For example, a worksite-based product which uses an individual policy form but is marketed to an employer group is an individual coverage basis.
A policy decision about categories of health interventions or benefits that will be provided to a population of patients as part of the contract between a health plan and a beneficiary.
Refers to three types of entities that must comply with federal health information privacy regulations (e.g., HIPAA Privacy Rule): health care providers, health plans, and health care clearinghouses. For these purposes, health care providers include hospitals, physicians, and other caregivers, as well as researchers, who provide health and care receive, access, or generate individually identifiable health care information.
Health care services covered by an insurance plan.
The recognition of professional or technical competence. The recredentialing process may include registration, certification, licensure, professional association membership, or the award of a degree in the field. Certification and licensure affect the supply of health personnel by controlling entry into practice and influence the stability of the labor force by affecting geographic distribution, mobility, and retention of workers. Credentialing also determines the quality of personnel by providing standards for evaluating competence and by defining the scope of functions and how personnel may be used.
Critical Access Hospital (CAH)
A rural hospital designation established by the Medicare Rural Hospital Flexibility Program (MRHFP) enacted as part of the 1997 Balanced Budget Act. Rural hospitals meeting criteria established by their state may apply for critical access hospital status. Designated hospitals are reimbursed based on cost (rather than prospective payment), must comply with federal and state regulations for CAHs, and are exempt from certain hospital staffing requirements.
A phenomenon whereby new public programs or expansions of existing public programs designed to extend coverage to the uninsured prompt some privately insured persons to drop their private coverage and take advantage of the expanded public subsidy.
Current Annual Premium
The amount of annual premium being paid for the coverage, including both the insured's portion and any portion paid by the employer, if applicable. This would reflect the current premium amount such that any voluntary changes in coverage that might have increased or decreased the premium from its original issue amount would be reflected in this figure.
Refers to an insured who is in active claim status which means that they meet the definition of chronically ill and are receiving benefit payments in accordance with the coverage provisions and requirements of the policy or certificate.
Current Population Survey (CPS)
A national survey conducted annually by the U.S. Department of Commerce, Bureau of the Census, the CPS gathers information on the noninstituionalized population of the United States. The CPS is the most commonly reported source for the number of persons without health insurance and other information about this population.
Current Procedural Terminology, Fourth Edition (CPT-4)
A manual that assigns five digit codes to medical services and procedures to standardize claims processing and data analysis.
Care that does not require specialized training or services. (See also personal care.)
One of the factors determining a physician's payment for a service under Medicare. Calculated as the physician's median charge for that service over a prior 12-month period.
Customary, Prevailing, and Reasonable (CPR)
Current method of paying physicians under Medicare. Payment for a service is limited to the lowest of : (1) the physician's billed charge for the service; (2) the physician's customary charge for the service; or (3) the prevailing charge for that service in the community. Similar to the Usual, Customary, and Reasonable system used by private insurers.
A process whereby information that could identify the clinician, the reporter, the health care institution, or another organization involved in a medical error are removed from an error report after it is received. This process is used to maintain records of factors that could cause errors, but assure those who report errors that their reports will not be used in civil lawsuits against them.
Initial amount of claims incurred by the policyholder not covered by the insurance policy. Insurance coverage begins only for losses incurred above the deductible amount.
The amount of loss or expense that must be incurred by an insured or otherwise covered individual before an insurer will assume any liability for all or part of the remaining cost of covered services. Deductibles may be either fixed-dollar amounts or the value of specified services (such as two days of hospital care or one physician visit). Dedictibles are usually tied to some reference period over which they must be incurred (e.g., $100 per calendar year, benefit period, or spell of illness).
Policy which calls for the provision of supportive care and treatment for medically and socially dependent individuals in the community rather than in an institutional setting.
Funding mechanisms for pension plans that can also be applied to health benefits. Typical pension approaches include: (1) pegging benefits to a percentage of an employee's average compensation over his/her entire service or over a particular number of years; (2) calculation of a flat monthly payment; (3) setting benefits based upon a definite amount for each year of service, either as a percentage of compensation for each year of service or as a flat dollar amount for each year of service.
Funding mechanism for pension plans that can also be applied to health benefits based on a specific dollar contribution, without defining the services to be provided.
Term which describes a group of diseases (including Alzheimer's Disease) which are characterized by memory loss and other declines in mental functioning.
The sampling variance of the actual complex design used to select a sample divided by the sampling variance of a simple random sample of the same size. This measure reflects the effect on the precision of a survey estimate due to the difference between the sample design actually used to collect data and a simple random sample.
Provision of information about drug products by sales representatives of the pharmaceutical industry to physicians to influence the physicians' prescribing behavior. Counter detailing is the educational efforts by health care purchasers or insurers to influence physicians' prescribing behaviors, often to counter the detailing efforts of pharmaceutical manufacturers.
Developmental Disability (DD)
A disability which originates before age 18, can be expected to continue indefinitely, and constitutes a substantial handicap to the disabled's ability to function normally.
A severe, chronic disability that is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the person attains age 22; is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity of independent living, economic self-sufficiency; and reflects the person's needs for a combination and sequence of special, interdisciplinary, or generic care treatments of services which are of lifelong or extended duration and are individually planned and coordinated.
Diagnosis-Related Group (DRG)
A classification system which uses diagnosis information to establish hospital payments under Medicare. This system groups patient needs into 467 categories, based upon the coding system of the International Classification of Disease, Ninth Revision-Clinical Modification (ICD-9-CM).
Groupings of diagnostic categories drawn from the International Classification of Diseases and modified by the presence of a surgical procedure, patient age, presence or absence of significant comorbidities or complications, and other relevant criteria. DRGs are the case-mix measure used in Medicare's prospective payment system.
Diagnostic and Statistical Manual of Mental Disorders (DSM)
A tool used by the medical and psychological communities to identify and classify behavioral, cognitive, and emotional problems according to a standard numerical coding system of mental disorders.
A cost which is identifiable directly with a particular activity, service, or product of the program experiencing the costs. These costs do not include the allocation of costs to a cost center which are not specifically attributable to that cost center.
Direct Patient Care
Any activities by a health professional involving direct interaction, treatment, administration of medications, or other therapy or involvement with a patient.
Direct to Consumer (DTC) Advertising
The advertising of prescription drugs (or other products) directly to consumers via various conventional means such as television, radio, or periodicals. DTC advertising can be in lieu of, or in addition to, marketing efforts targeting physicians or other health care professionals.
The limitation of normal physical, mental, social activity of an individual. There are varying types (functional, occupational, learning), degrees (partial, total), and durations (temporary, permanent) of disability. Benefits are often available only for specific disabilities, such as total and permanent (the requirement for Social Security and Medicare).
An exercise, or demonstration, that tests the readiness and capacity of a hospital, a community, or other system to respond to a public health emergency or other disaster.
The release of a patient from a provider's care, usually referring to the date at which a patient checks out of a hospital.
May be defined as a failure of the adaptive mechanisms of an organism to counteract adequately, normally, or appropriately to stimuli and stresses to which it is subjected, resulting in a disturbance in the function or structure of some part of the organism. This definition emphasizes that disease is multi-factorial and may be prevented or treated by changing any or a combination of the factors. Disease is a very elusive and difficult concept to define, being largely socially defined. Thus, criminality and drug dependence are presently seen by some as diseases, when they were previously considered to be moral or legal problems.
The process of identifying and deliving within the selected patient populations (e.g., patients with asthma or diabetes) the most efficient, effective combination of resources, interventions, or pharmaceuticals for the treatment or prevention of a disease. Disease management could include team-based care where physicians and/or other health professionals participate in the delivery and management of care. It also includes the appropriate use of pharmaceuticals.
Disproportionate Share Adjustment
A payment adjustment under Medicare's prospective payment system or under Medicaid for hospitals that serve a relatively large volume of low-income patients.
Do Not Resuscitate Order
(Also called a DNR order, a No CPR order, a DNAR order (do not attempt resuscitation), and an AND order (allow natural death).) A physician's order written in a patient's medical record indicating that health care providers should not attempt CPR in the event of cardiace or respiratory arrest. In some regions, this order may be transferable between medical venues.
Drug Claims Processing
An automated assessment of drug claims at the point of service, meant to detect potential problems that should be addressed before drugs are dispensed to patients (for example, checking patients' eligibility for drug coverage or checking whether the prescription has been filled at another pharmacy in the last prescription cycle).
Drug Risk-Sharing Arrangements
Health care provider organizations may be at partial, full, or no risk for drug costs. Provider groups at partial risk share in a proportion of savings and/or cost overruns. The group can share in savings if it prescribes less than the budgeted amount ("upside risk"), and it may also share in any over-expenditures ("downside risk"). Groups at full risk realize all of the savings or absorb all of the losses. Groups at no risk absorb none of the losses and profits (typically, risks are absorbed by the HMO or other managed care organization).
Drug Utilization Review (DUR)
A formal program for assessing drug prescription and use patterns. DURs typically examine patterns of drug misuse, monitor current therapies, and intervene when prescribing or utilization patterns fall outside pre-established standards. DUR is usually retrospective, but can also be performed before drugs are dispensed. DURs were established by the OBRA in 1990 and are required for Medicaid programs.
A person who is eligible for two health insurance plans, often referring to a Medicare beneficiary who also qualifies for Medicaid benefits.
Durable Medical Equipment (DME)
(Also called home medical equipment.) Equipment such as hospital beds, wheelchairs, ventilator, oxygen system, home dialysis system, and prosthetics used at home. May be covered by Medicaid and in part by Medicare or private insurance. Prescribed by a physician for a patient's use for an extended period of time.
Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT)
A program mandated by law as part of the Medicaid program. The law requires that all states have in effect a program for eligible children under age 21 to ascretain their physical or mental defects and to provide such health care treatments and other measures to correct or ameliorate defects and chronic conditions discovered. The state programs also have active outreach components to inform eligible persons of the benefits available to them, to provide screening, and if necessary, to assist in obtaining appropriate treatment.
Civil litigation is compensation due the plainiff for financial losses caused by the wrongful actions of another party (e.g., awards for the medical bills of a nursing home resident caused by an abusive employee).
Effective Sample Size
The actual sample size divided by the design effect that reflects the effect of the deviations form simple random sampling.
A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunications to a health insurance payer.
Electronic Data Interchange (EDI)
The mutual exchange of routine information between business using standardized, machine-readable formats.
Emergency Medical Services (EMS)
Services utilized in responding to the perceived individual need for immediate treatment for medical, physiological, or psychological illness or injury.
Facilities used solely for out-of-home placement on a short-term basis during periods or sudden emergency, pending formulation or long-term solutions.
Employee Retirement Income Security Act (ERISA)
A federal act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs.
The name of the employer identified as the group policyholder.
The category of the employer as expressed using standard industry codes.
A contact between an individual and the health care system for a health care service or set of services related to one or more medical conditions.
A plan relating to tort reform in which medical liability is shifted from physicians to health plans (e.g., HMOs). Under such a system, patients would sue the health plan rather than the physician, thereby providing physicians immunity from medical liability.
A group of cases of a specific disease or illness clearly in excess of what one would normally expect in a particular geographic area. There is no absolute criterion for using the term epidemic; as standards and expectations change, so might the definition of an epidemic (e.g., an epidemic of violence).
The study of the patterns of determinants and antecedents of disease in human populations. It utilizes biology, clinical medicine, and statistics in an effort to understand the etiology (causes) of illness and/or disease. The ultimate goal of the epidemiologist is not merely to identify underlying causes of a disease but to apply findings to disease prevention and health promotion.
(Also called transportation services.) Provides transportation for older adults to services and appointments. May use bus, taxi, volunteer drivers, or van services that can accommodate wheelchairs and persons with other special needs.
By law states are required to recover funds from certain deceased Medicaid recipients' estates up to the amount spent by the state for all Medicaid services (e.g., nursing facility, home and community-based services, hospital, and prescription costs).
Estimated Liability Costs
Approximate calculations of expenses for damages to which a nursing home is exposed. Because estimates re derived from information provided by nursing homes and the cost of settlements of lawsuits is confidential information known only to the insurance carrier, plaintiff's attorney and defense attorney, these calculations are only estimates and are subject to change.
Estimator (biased, unbiased)
A random variable used to estimate the value of a population parameter from sample data. Its value depends on the particular sample involved. If the expected value of the estimator over all possible samples is equal to the quantity it estimates, the estimator is unbiased. If it does not, it is biased.
Evidence-Based Decision Making
In a health policy context, evidence-based decision making is the application of the best available scientific evidence to policy decisions about specific medical treatments or changes in the delivery system. The goals of evidence-based decision making are to improve the quality of care, increase the efficiency of care delivery, and improve the allocation of health care resources.
Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. This approach must balance the best external evidence with the desires of the patient and the clinical expertise of health care providers.
Exclusive Provider Arrangement (EPA)
An indemnity or service plan that provides benefits only if care is rendered by the institutional and professional providers with which it contracts (with exceptions for emergency and out-of-area services).
Expenditure Target (ET)
A mechanism to adjust fee updates (or the fees themselves) based on how actual expenditures in an area compare to a target for those expenditures.
A method of adjusting health plan premiums based on the historical utilization data and distinguishing characteristics of a specific subscriber group.
Family and Medical Leave Act (FMLA)
A 1993 federal law requiring employers with more than 50 employees to provide eligible workers up to 12 weeks of unpaid leave for birth, adoptions, foster care placement, and illnesses of employees and their families.
Family Foster Home
Non-secure, 24-hour, residential care in a permanent or temporary family setting (include adoptive placements that have not yet been finalized, and relatives only if they are licensed or reimbursed).
A form of specialty practice in which physicians provide continuing comprehensive primary care within the context of the family unit.
A tendency for utilization of health services in a population group to be lower than expected or estimated.
Federal Employees Health Benefits Program (FEHBP)
A voluntary health insurance subsidy program administered by the Office of Personnel Management for civilian employees (including retirees and dependents) of the Federal Government. Enrollees select from a number of approved plans, the costs of which are primarily borne by the government.
Federal Poverty Level (FPL)
The amount of income determined by the federal Department of Health and Human Services to provide a bare minimum for food, clothing, transportation, shelter, and other necessities. FPL is reported annually and varies according to family size (e.g., for a family of three in 1999, the FPL was $13,880, or $1,157 per month). Public assistance programs usually define income limits in relation to FPL.
Federally Qualified Health Center (FQHC)
A health center in a medically under-served area that is eligible to receive cost-based Medicare and Medicaid reimbursement and provide direct reimbursement to nurse practitioners, physician assistants, and certified nurse midwives.
A list of physician services in which each entry is associated with a specific monetary amount that represents the approved payment level for a given insurance plan.
Method of billing for health services under which a physician or other practitioner charges separately for each patient encounter or service rendered; it is the method of billing used by the majority of U.S. physicians. Under a fee-for-service payment system, expenditures increase if the fees themselves increase, if more units of service are provided, or if more expensive services are substituted for less expensive ones. This sytem contrasts with salary, per capita, or other prepayment systems, where the payment to the physician is not changed with the number of services actually used.
Relating to, or founded upon, a trust or confidence. A fiduciary relationship exists where an individual or organization has an explicit or implicit obligation to act in behalf of another person's or organization's interests in matters that affect the other person or organization. A physician has such a relation with his/her patient, and a hospital trustee has one with a hospital.
Organization or company in which profits are distributed to shareholders or private owners.
A list of drugs, usually by their generic names, and indications for their use. A formulary is intended to include a sufficient range of medicines to enable physicians, dentists, and, as appropriate, other practitioners to prescribe all medically appropriate treatment for all reasonably common illnesses. An "open" formulary allows a coverage for almost all drugs. A "closed" formulary provides coverage for a limited set of drugs. A "managed" formulary includes a list of preferred drugs that the health plan prefers to use because they cost less, are more effective, or for other reasons. A "tiered" formulary financially rewards patients for using generic and formulary drugs by requiring the patient to pay progressively higher copayments for brand-name and nonformulary drugs. For example, in a three-tiered benefit structure, copayments may be $5 for a generic, $10 for a formulary brand product, and $25 for a nonformulary brand product.
Any of the following out-of home placements under the jurisdiction of the primary state child welfare agency and regarded as 24-hour substitute care, not including finalized adaptive home placements, placement with relatives who are not licensed or reimbursed, or placement made by state agencies other than the primary child welfare agency: family foster home, group home, group home 21+, emergency shelter, secure facility, independent living, parents or relative.
Any child in public foster care, or in private foster care but under the case management and planning responsibility of the primary state child welfare agency, who is 0-17 years old, or 18,19, or 20 years old and entered foster care before age 18.
Foundation for Accountability (FACCT)
FACCT is a not-for-profit organization dedicated to helping Americans make better health care decisions. FACCT's board of trustees is made up of consumer organizations and purchasers of health care services and insurance representing 80 million Americans. FACCT creates tools that help people understand and use quality information, develops consumer-focused quality measures, supports public education about health care quality, supports efforts to gather and provide quality information, and encourages health policy to empower and inform consumers.
Frequency of Future Purchase Option
Indicates whether the FPO is made on an annual basis, or on a frequency less often than that (e.g., every two or three years).
Future Purchase Option (FPO)
The type of periodic benefit increase which allows the individual to purchase additional increments of coverage for additional premium amounts based on their attained age at the time they elect the increase. These coverage increases are available at set time periods (annually or otherwise) and are available to the insured who wishes to elect them without requiring evidence of insurability.
The primary care practitioner in managed care organizations who determines whether the presenting patient needs to see a specialist or requires other nonroutine services. The goal is to guide the patient to appropriate services while avoiding unnecessary and costly referrals to specialists.
General Liability Claims/Losses
Amounts a nursing home liability insurer is legally obligated to pay as damages to a plaintiff due to bodily injury or property damage.
A form of practice in which physicians without specialty training provide a wide range of primary health care services to patients.
In cases in which the patent on a specific pharmaceutical product expires and drug manufacturers produce generic versions of the original branded product, the generic version of the drug (which is theorized to be identical to the product manufactured by a different firm) is dispensed even though the original product is prescribed. Some managed care organizations and Medicaid programs mandate generic substitution because of the generally lower cost of generic products. There are state and federal regulations regarding generic substitutions.
The study of genomes, which includes gene mapping, gene sequencing, and gene function.
Physician who is certified in the care of older people.
Medical specialty focusing on treatment of health problems of the elderly.
Study of the biological, psychological and social processes of aging.
A method of hospital cost containment in which participating hospitals must share a prospectively set budget. Method for allocating funds among hospitals may vary but the key is that the participating hospitals agree to an aggregate cap on revenues that they will receive each year. Global budgeting may also be mandated under a universal health insurance system.
A total charge for a specific set of services, such as obstetrical services that encompass prenatal, delivery, and post-natal care.
Graduate Medical Education (GME)
Medical education after receipt of the Doctor of Medicine (MD) or equivalent degree, including the education received as an intern, resident (which involves training in a specialty), or fellow, as well as continuing medical education. CMS partly finances GME through Medicare direct and indirect payments.
(Also called adult care home or board and care home.) Residence which offers housing and personal care services for 3 to 16 residents. Services (such as meals, supervision, and transportation) are usually provided by the owner or manager. May be single family home. (Licensed as adult family home or adult group home.)
(Also called shelter or half-way house.) Non-secure, 24-hour residential care facility serving up to 20 persons which provides nonspecialized physical care and may or not offer an educational program on site.
Group Home 21+
(Also called residential treatment facility or child care institution.) Nonsecure, 24-hour, residential care facility serving 21 or more persons which provides nonspecialized physical care and may or may not offer a therapeutic service or an educational program for emotionally disturbed or otherwise handicapped youth.
A formal association of three or more physicians or other health professionals providing health services. Income from the practice is pooled and redistributed to the members of the group according to some prearranged plan (often, but not necessarily, through partnership). Groups vary a great deal in size, composition, and financial arrangements.
Requirement that insurance carriers offer coverage to groups and/or individuals during some period each year. HIPAA requires that insurance carriers guarantee issue of all products to small groups (2-50). Some state laws exceed HIPAA's minimum standards and require carriers to guarantee issue to additional groups and individuals.
Requirement that insurance carriers renew existing coverage to groups and/or individuals. HIPAA requires that insurance issuers guarantee renewal of all products to all groups and individuals.
A judicially appointed guardian or conservator having authority to make a health care decision for an individual.
As defined by Section 504 of the Rehabilitation Act of 1973, any person who has a physical or mental impairment which substantially limits one or more major life activity, has a record of such impairment, or is regarded as having such an impairment.
Those individuals diagnosed as having a handicapping condition in accordance with the following definitions: mentally retarded; seriously emotionally disturbed; specific learning disability; hearing, speech, or sight impaired; physical or health handicapped. Persons should not be counted as handicapped unless they have been clinically diagnosed as having these conditions. Use one primary diagnosis for multiply handicapped children.
The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anatomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms or morbidity and mortality.
Health Care Paraprofessional
Home health aides, certified nurses aids, and personal care attendants who provide direct care and personal support services in hospitals, nursing homes, other institutions, as well as home-based care to the disabled, aged, and infirm.
Any combination of learning opportunities designed to facilitate voluntary adaptations of behavior (in individuals, groups, or communities) conducive to health.
Collectively, all physical plants used in the provision of health services--usually limited to facilities that were built for the purpose of providing health care, such as hospitals and nursing homes. They do not include an office building that includes a physician's office. Health facility classifications include: hospitals (both general and apecialty), long-term care facilities, kidney dialysis treatment centers, and ambulatory surgical facilities.
Financial protection against the medical care costs arising from disease or accidental bodily injury. Such insurance usually covers all or part of the medical costs of treating the disease or injury. Insurance may be obtained on either an individual or a group basis.
Health Insurance Flexibility and Accountability (HIFA)
The primary goal of the HIFA demonstration initiative is to encourage new comprehensive state approaches that will increase the number of individuals with health insurance coverage within current level Medicaid and State Children's Health Insurance Program (SCHIP) resources. The program utilizes CMS Section 1115 waiver authority and emphasizes broad statewide approaches that maximize private health insurance coverage options and target Medicaid and SCHIP resources to populations with incomes below 200% of the federal poverty level.
Health Insurance Portability and Accountability Act (HIPAA)
Federal health insurance legislation passed in 1996, which sets standards for access, portability, and renewability that apply to group coverage--both fully insured and self-funded--as well as to individual coverage. HIPAA allows under specified conditions, for long-term care insurance policies to be qualified for certain tax benefits under Section 7702(b) of the Internal Revenue Code.
Health Insurance Purchasing Cooperative (HIPC)
Public or private organization that secures health insurance coverage for the workers of all member employers. The goal of these organizations is to consolidate purchasing responsibilities to obtain greater bargaining clout with health insurers, plans and providers to reduce the administrative costs of buying, selling, and managing insurance policies. Private cooperatives are usually voluntary associations of employers in a similar geographic region who band together to purchase insurance for their employees. Public cooperatives are established by state governments to purchase insurance for public employees, Medicaid beneficiaries, and other designated populations.
Health Maintenance Organization (HMO)
Managed care organization that offers a range of health services to its members for a set rate, but which requires its members to use health care professionals who are part of its network of providers. (See also Medicare HMOs.)
Health Manpower Shortage Area (HMSA)
An area or group which HHS designates as having an inadequate supply of health care providers. HMSAs can include: (1) an urban or rural geographic area, (2) a population gorup for which access barriers can be demonstrated to prevent members of the group from using local providers, or (3) medium and maximum-security correctional institutions and public or nonprofit private residential facilities.
Collectively, all persons working in the provision of health services, whether as individual practitioners or employees of health institutions and program, whether or not professionally trained, and whether or not subject to public regulation. Facilities and health personnel are the principal health resources used in producing health services.
An organization that provides a defined set of benefits. This term usually refers to an HMO-like entity, as opposed to an indemnity insurer.
Health Plan Employer Data and Information Set (HEDIS)
A set of performance measures for health plans developed for the National Committee for Quality Assurance (NCQA) that provides purchasers with information on effectiveness of care, plan finances and costs, and other measures of plan performance and quality.
Planning concerned with improving health, whether undertaken comprehensively for a whole community or for a particular poulation, type of health service, institution, or health program. The components of health planning include: data assembly and analysis, goal determination, action recommendation, and implementation strategy.
An insurance contract consisting of a defined set of benefits. See health insurance.
Any combination of health education and related organizational, political, and economic interventions designed to facilitate behavioral and environmental adaptations that will improve or protect health.
Health-Related Quality of Life (HRQL)
In public health and in medicine, the concept of HRQL refers to a person or group's perceived physical and mental health over time. Physicians have often used HRQL indicators to measure the effects of chronic illness in their patients in order to better understand how an illness interferes with a person's day-to-day life. Similarly, public health professionals use HRQL indicators to measure the effects of numerous disorders, short and long-term disabilities, and diseases in different populations. Tracking HRQL in different populations can identify subgroups with poor physical or mental health and can help guide policies or interventions to improve their health.
Health Risk Factors
Chemical, psychological, physiological, or genetic factors and conditions that predispose an individual to the development of a disease.
Health Service Area
Geographic area designated on the basis of such factors as geography, political boundaries, population, and health resources, for the effective planning and development of health services.
Health Services Research
Health services research is the multi-disciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations.
The state of health of a specified individual, group, or population. It may be measured by obtaining proxies such as people's subjective assessments of their health; by one or more indicators of mortality and morbidity in the population, such as longevity or maternal and infant mortality; or by using the incidence or prevalence of major diseases (communicable, chronic, or nutritional). Conceptually, health status is the proper outcome measure for the effectiveness of a specific population's medical care system, although attempts to relate effects of available medical care to variations in health status have proved difficult.
Health Systems Agency (HSA)
A health planning agency created under the National Health Planning and Resources Development Act of 1974. HSAs were usually nonprofit private organizations and served defined health service areas as designated by the states.
Health Technology Assessment (HTA)
The systematic evaluation of properties, effects, or other impacts of health care technology. HTA is indended to inform decision-makers about health technologies and may measure the direct or indirect consequences of a given technology or treatment.
Healthcare Cost and Utilization Project Quality Indicators (HCUP QIs)
HCUP QIs comprise a set of 33 clinical performance measures that inform hospitals' self-assessments of inpatient quality of care, as well as state and community assessments of access to primary care. Developed by the Agency for Healthcare Research and Quality as a quick and easy-to-use screening tool, HCUP QIs are intended as a starting point in identifying clinical areas appropriate for further, more in-depth study and analysis. HCUP QIs span three dimensions of care: (1) potentially avoidable adverse hospital outcomes; (2) potentially inappropriate utilization of hospital procedures; and, (3) potentially potentially avoidable hospital admissions.
A subsidized health insurance pool organized by some states as an alternative for individuals who have been denied health insruance because of a medical condition, or whose premiums are rated signficantly higher than the average due to health status or claims experience. Commonly operated through an association composed of all health insurers in a state. HIPAA allows states to use high-risk pools as an "acceptable alternative mechanism" that satisfies the statutory requirements for ensuring access to health insurance coverage for certain individuals.
Coined from the names of the principal sponsors of the Public Law 79-725 (the Hospital Survey and Construction Act of 1946). This program provided federal support for the construction and modernization of hospitals and other health facilities. Hospitals that have received Hill-Burton funds incur an obligation to provide a certain amount of charity care.
A bias in investigating the cause of a medical error or accident where in retrospect the reviewer simplifies the cause of the error to a single element, overlooking multiple contributing factors. The hindsight bias makes it easy to arrive at a simple solution or to blame an individual, but often makes it difficult to determine the true cause(s) of the error or propose systematic solutions.
A contractual requirement prohibiting a provider from seeking payment from an enrollee for services renedered prior to a health plan insolvency.
Refers to the integration of mind, body, and spirit of a person and emphasizes the importance of perceiving the individual (regarding physical symptoms) in a "whole" sense. Holism teaches that the health care system must extend its focus beyond solely the physical aspects of disease and particular organ in question, to concern itself with the whole person and the interrelationships between the emotional, social, spiritual, as well as physical implications of disease and health.
Home and Community-Based Services (HCBS)
Any care or services provided in a patient's place of residence or in a noninstitutional setting located in the immediate community. HCBS may include home health care, adult day care or day treatment, medical services, or other interventions provided for the purpose of allowing a patient to receive care at home or in their community.
Home and Community-Based Waivers
Section 2176 of the Omnibus Reconciliation Act permits states to offer, under a waiver, a wide array of home and community-based services that an individual may need to avoid institutionalization. Regulations to implement the act list the following services as community and home-based services which may be offered under the waiver program: case management, homemaker, home health aide, personal care, adult day health care, habilitation, respite care and other services.
Services provided at a patient's place of residence (typically a patient's home), in compliance with a physician's written plan of care that is reviewed every 62 days--including nursing services, as defined in the State Nurse Practice Act, home health aide services, physical therapy, occupational therapy or speech pathology, and audiology services--that are provided by a home health agency or by a facility licensed by the state to provide these medical rehabilitation services.
Home Health Agency (HHA)
A public or private organization that provides home health services supervised by a licensed health professional in the patient's home either directly or through arrangements with other organizations.
Home Health Aide
A person who, under the supervision of a home health or social service agency, assists elderly, ill or disabled person with household chores, bathing, personal care, and other daily living needs. Social service agency personnel are sometimes called personal care aides.
Home Health Care
Includes a wide range of health-related services such as assistance with medications, wound care, intravenous (IV) therapy, and help with basic needs such as bathing, dressing, mobility, etc., which are delivered at a person's home.
Health services rendered in the home to the aged, disabled, sick, or convalescent individuals who do not need institutional care. The services may be provided by a visiting nurse association, home health agency, country public health department, hospital, or other organized community group and may be specialized or comprehensive. The most common types of home health care are the following--nursing services; speech, physical, occupational and rehabilitation therapy; homemaker services; and social services.
Home Health Care Benefit Amount
The maximum amount which the policy or certificate will pay for care received at home (or for home and other community care benefits). If the benefit is paid as weekly or monthly, the daily amount should be derived by whatever convention is most appropriate for the carrier to use. The data should be the current amount on the policy in order to account both for any voluntary increases in coverage the insured has elected or any automatic coverage increaess as a result of inflation protection.
Home Health Care Benefits Paid During Report Period
The total amount of benefits paid during the reporting period for care at home or in a noninstitutional covered care setting (e.g., adult day care) as defined as "home or community-based care" within the policy or certificate.
Home Medical Equipment
(Also called durable medical equipment.) Equipment such as hospital beds, wheelchairs, and prosthetics used at home. May be covered by Medicaid and in part by Medicare or private insurance.
One of the requirements to qualify for Medicare home health care. Means that someone is generally unable to leave the house, and if they do leave home, it is only for a short time (e.g., for a medical appointment) and requires much effort.
In-home help with meal preparation, shopping, light housekeeping, money management, personal hygiene and grooming, and laundry.
Merging of two or more firms at the same level of production in some formal, legal relationship.
A program which provides palliative and supportive care for terminally ill patients and their families, either directly or on a consulting basis with the patient's physician or another community agency. The whole family is considered the unit of care, and care extends through their period of mourning.
Services for the terminally ill provided in the home, a hospital, or a long-term care facility. Includes home health services, volunteer support, grief counseling, and pain management.
An institution whose primary function is to provide inpatient diagnostic and therapeutic services for a variety of medical conditions, both surgical and nonsurgical.
Any loss or abnormality of psychological, physiological, or anatomical function.
Independent Living Facility
Rental units in which services are not included as part of the rent, although services may be available on site and may be purchased by residents for an additional fee.
A facility (house, apartment, etc.) in which a child/youth is permitted to live or reside "independently" without a paid caretaker.
Health services provided to the poor or those unable to pay. Since many indigent patients are not eligible for federal or state programs, the costs which are covered by Medicaid are generally recorded separately from indigent care costs.
Cost which cannot be identified directly with a particular activity, service or product of the program experiencing the cost. Indirect costs are usually apportioned among the program's services in proportion to each service's share of direct costs.
An individual's direction concerning a health care decision. This may be written or verbal describing goals for health care, treatment preferences, or willingness to tolerate future health states.
Inflation Protection Duration Type: Attained Age of Policy/Certificate
The type of inflation that ends when the insured has received annual benefit increases for a predefined number of years (e.g., 10 or 20 years).
Inflation Protection Duration: Attended Age of Insured
The type of inflation protection that ends when the insured reaches a specified age (e.g., age 80, or others).
Inflation Protection Duration: Life of Policy/Certificate
The type of inflation protection that continues through the life of the coverage, and continues even while the insured is in claim status (receiving benefits).
Inflation Protection Duration: When Benefit Has Doubted
The type of inflation protection that continues until the daily benefit amount for nursing home care has doubled from its original value at time of purchase.
Inflation Protection Increase Amount or Index Value
The specific percentage increase applied to benefits each year designed to keep pace with inflation, if it is a set amount as previously defined. If the increase is based on an index, the specific increase amount expressed in terms of a percent of the prior year's increase, that is applicable to the current reporting period.
A person who has been admitted at least overnight to a hospital or other health facility (which is therefore responsible for his or her room and board) for the purpose of receiving diagnostic treatment or other health services.
Institutional Health Services
Health services delivered on an inpatient basis in hospitals, nursing homes, or other inpatient institutions. The term may also refer to services delivered on an outpatient basis by departments or other organizational units of, or sponsored by, such institutions.
Institutional Long-Term Care (ILTC)
Nursing facility services, services provided in ICFs/MR, mental hospital services for people over age 65, and inpatient psychiatric facility services for individuals under age 21.
Instructional Health Care Directive
(Also called a living will.) A written directive describing preferences or goals for health care, or treatment preferences or willingness to tolerate health states, aimed at guiding future health care.
Instrumental Activities of Daily Living (IADLs)
Household/independent living tasks which include using the telephone, taking medications, money management, housework, meal preparation, laundry, and grocery shopping.
Occasional nursing and rehabilitative care ordered by a doctor and performed or supervised by skilled medical personnel.
Intermediate Care Facility (ICF)
A nursing home, recognized under the Medicaid program, which provides health-related care and services to individuals who do not require acute or skilled nursing care, but who, because of their mental or physical condition, require care and services above the level of room and board available only through facility placement. Specific requirements for ICF's vary by state. Institutions for care of the mentally retarded or people with related conditions (ICF/MR) are also included. The distinction between "health-related care and services" and "room and board" is important since ICF's are subject to different regulations and coverage requirements than institutions which do not provide health-related care and services.
Intermediate Care Facility for the Mentally Retarded (ICF/MR)
An ICF which cares specifically for the mentally retarded.
International Classification of Diseases, ninth edition (Clinical Modification) (ICD-9-CM)
A list of diagnoses and identifying codes used by physicians and other health care providers. The coding and terminology provide a uniform language that permits consistent communication on claim forms.
International Classification of Functioning, Disability and Health (ICF)
An internationally standardized list of identifying codes and definitions of human functioning and disabilities organized by body functions and structures, domains of activities and participation, and environmental factors. The coding and terminology provide a uniform language that permits consistent communication on claim forms.
Refers to "endotracheal intubation" the insertion of a tube through the mouth or nose into the trachea (windpipe) to create and maintain an open airway to assist treathing.
A detailed description of quantities and locations of different kinds of facilities, major equipment, and personnel which are available in a geographic area and the amount, type, and distribution of services these resources can support.
Joint and Several Liability
In civil litigation is a situation in which the concurrent acts of two or more defendants bring harm to the plantiff. Such acts need not occur simultaneously, but must contribute to the same event. In such a case, the damages may be collected from one or more of the defendants. If the court does not apportion blame in specific shares, the damages may be collected from any and all defendants. If a defandant does not have the financial wherewithal to pay, the others must make up the difference.
Joint Underwriting Association
A state-sponsored organization that creates insurance pools and functions as an insurer in markets without a significant number of licensed insurers. It has the power to sell insurance policies, collect premiums, and purchase reinsurance and it can usually guarantee a certain level of premium rates to its members. It can also levy surcharges on policyholders and, in some cases, on licensed insurers selling liability insurance, to create reserves to pay claims.
None at this time.
A disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculation. The term includes such conditions as perceptual handicaps, brain injury, and minimal brain dysfunction.
Level of Care (LOC)
Amount of assistance required by consumers which may determine their eligibility for programs and services. Levels include: protective, intermediate, and skilled.
Level of Care Criteria
Guidelines employed to assist in determining the appropriate setting and intensity of behavioral health treatment.
A permission granted to an individual or organization by a competent authority, usually public, to a engage lawfully in a practice, occupation, or activity.
Medical procedures that replace or support an essential bodily funciton. Life-sustaining treatments include CPR, mechanical ventilation, artificial nutrition and hydration, dialysis, and certain other treatments.
Lifetime Maximum Structure (LMS)
Whether there is a single lifetime maximum for all services and benefits covered by the policy, or whether there are separate lifetime maximums for the major policy benefits such as nursing home care versus home care. Limits that are specific to smaller benefits like respite care, caregiver training or medical devices and the like are not considered. LMS refers primarily to whether there is a single "pool" for either facility and home care benefits or whether thre are separate "pools" for the major benefit categories of nursing home, assisted living, and home and community care. While the prevailing benefit structure today is a single lifetime maximum for all covered services, there are some policies being sold today which have separate lifetime maximums for these major covered services.
Lifetime Maximum Structure (LMS) Detail
The basis on which total benefits paid under the policy are determined in terms of either days or dollars. This refers to whether the policy or certificate counts days on which benefits have been received or whether it counts dollars of benefits paid out in determining when the coverage's lifetime maximum has been met. While the prevailing policy design today is a "pool of dollars" benefit approach, some policies being sold today still count days on which benefits are paid in determining the policy's lifetime maximum.
Lifetime Policy Maximum for ALD/Other Facility Care (Dollars)
If the coverage uses a pool of dollars design and has separate pools for the major covered services, this is where the dollar amount which represents the lifetim maximum paid for ALF care would be specified. If the policy combines nursing home and ALF care into a single "facility care lifetime maximum" this entry would be indicated as "not applicable."
Lifetime Policy Maximum for ALF/Other Facility Care Benefits (Days)
If the coverage uses days of benefit received to calculate the policy maximum and has separate pools for the major covered services, this is where the number of days which represents the lifetime maximum paid for ALF care would be specified.
Lifetime Policy Maximum for Home Health Care (Dollars)
If the coverage uses a pool of dollars design and has separate pools for the major covered services, this is where the dollar amount which represents the lifetime maximum paid for home health care would be specified.
Lifetime Policy Maximum for Home Health Care Benefits (Days)
If the coverage uses days of benefit received to calculate the policy maximum and has separate pools for the major covered services, this is where the number of days which represents the lifetime maximum paid for home health care would be specified.
Lifetime Policy Maximum for Nursing Home Benefits (Days)
If the coverage uses days of benefit received to calculate the policy maximum and has separate pools for the major covered services, this is where the number of days which represents the lifetime maximum paid for nursing home care (or facility care all levels combined) would be specified.
Lifetime Policy Maximum for Nursing Home Coverage (Dollars)
If the coverage uses a pool of dollars design and has separate pools for the major covered services, this is where the dollar amount which represents the lifetime maximum paid for nursing home care (or facility care all levels combined) would be specified.
Long-Term Care (LTC)
Range of medical and/or social services designed to help people who have disabilities or chronic care needs. Services may be short- or long-term and may be provided in a person's home, in the community, or in residential facilities (e.g., nursing homes or assisted living facilities).
Long-Term Care Insurance (LTCI)
Insurance policies which pay for long-term care services (such as nursing home and home care) that Medicare and Medigap policies do not cover. Policies vary in terms of what they will cover, and may be expensive. Coverage may be denied based on health status or age.
Long-Term Care Ombudsman
An individual designated by a state or a substate unit responsible for investigating and resolving complaints made by or for older people in long-term care facilities. Also responsible for monitoring federal and state policies that relate to long-term care facilities, for providing information to the public about the problems of older people in facilities, and for training volunteers to help in the ombudsman program. The long-term care ombudsman program is authorized by Title III of the Older Americans Act.
Maintenance Assistance Status (MAS)
Eligibility grouping traditionally used by CMS to classify enrollees by the financial-related criteria by which they are eligible for Medicaid. MAS groups include cash assistance-related, medically needy, poverty-related, 1115 demonstration waiver, and other.
Managed Care (MC)
Method of organizing and financing health care services which emphasizes cost-effectiveness and coordination of care. Managed care organizations (including HMOs, PPOs, and PSOs) receive a fixed amount of money per client/member per month (called a capitation), no matter how much care a member needs during that month.
Payment mechanism used to manage health care, including services provided by health maintenance organizations or Programs of All-Inclusive Care for the Elderly, prepaid health plans, and primary care case management plans.
Maternal and Child Health Block Grant (Programs for Children with Special Needs)
There are no Federal criteria for defining children with special health care needs. These programs primarily served children with crippling conditions such as polio and cerebral palsy. However, these programs have expended to serve children with a wide range of chronic health conditions.
Mean Square Error
Measure of accuracy computed by squaring the individual errors (error is the difference between an actual value in a dataset and its expected value) and taking the mean of these squared values.
Treatment in which a mechanical ventilator supports or replaces the function of the lungs. The ventilator is attached to a tube inserted in the nose or mouth and down into the windpipe (or trachea). Mechanical ventilation often is used to assist a person through a short-term problem or for prolonged periods in which irreversible respiratory failure exists dur to injuries to the upper spinal cord or a progressive neurological disease.
Medicaid (Title XIX)
Federal and state-funded program of medical assistance to low-income individuals of all ages. There are income eligibility requirements for Medicaid.
A disabled individual must receive SSI in most States. Thirteen States use the 209(b) program option. They may impose additionally more restrictive eligibility criteria for Medicaid than for SSI. Three of these (Indiana, Missouri, and New Hampshire) employ more restrictive definitions of disability than that used by SSA and the latter two exclude children on SSI from Medicaid. In ten other States (Connecticut, Hawaii, Illinois, Minnesota, Nebraska, North Carolina, North Dakota, Ohio, Oklahoma, and Virginia), States use the same definition of disability, but more restrictive financial criteria than that used by SSI. In addition, State Medicaid programs may use functional criteria for coverage of nursing home services, home health services, personal care services, home and community-based waiver services, and other Medicaid-covered services. Two levels of disability criteria may be applied--one to determine overall Medicaid eligibility and one to determine eligibility for specific covered services.
Services or supplies which are appropriate and consistent with the diagnosis in accord with accepted standards of community practice and are not considered experimental. They also can not be omitted without adversely affecting the individual's condition or the quality of medical care.
People who cannot afford needed health care because of insufficient income and/or lack of adequate health insurance.
Medicare (Title XVIII)
Federal health insurance program for persons age 65 and over (and certain disabled persons under age 65). Consists of 2 parts: Part A (hospital insurance) and Part B (optional medical insurance which covers physicians' services and outpatient care in part and which requires beneficiaries to pay a monthly premium).
An individual under age 65 who received SSDI benefits for 24 months or more or who was medically determined to have end-stage renal disease (that stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life).
Under Medicare HMOs (health maintenance organizations), members pay their regular monthly premiums to Medicare, and Medicare pays the HMO a fixed sum of money each month to provide Medicare benefits (e.g., hospitalization, doctor's visits, and more). Medicare HMOs may provide extra benefits over and above regular Medicare benefits (such as prescription drug coverage, eyeglasses, and more). Members do not pay Medicare deductibles and co-payments; however, the HMO may require them to pay an additional monthly premium and co-payments for some services. If members use providers outside the HMO's network, they pay the entire bill themselves unless the plan has a point of service option.
Medicare Supplement Insurance (MedSupp)
(Also called Medigap.) Insurance supplement to Medicare that is designed to fill in the "gaps" left by Medicare (such as co-payments). May pay for some limited long-term care expenses, depending on the benefits package purchased.
(Also called Medicare supplement insurance. Insurance supplement to Medicare that is designed to fill in the "gaps" left by Medicare (such as co-payments). May pay for some limited long-term care expenses, depending on the benefits package purchased.
The capacity in an individual to function effectively in society. Mental health is a concept influenced by biological, environmental, emotional, and cultural factors and is highly variable in definition, depending on time and place. It is often defined in practice as the absence of any identifiable or significant mental disorder and sometimes improperly used as a synonym for mental illness.
Mental Health Services
Variety of services provided to people of all ages, including counseling, psychotherapy, psychiatric services, crisis intervention, and support groups. Issues addressed include depression, grief, anxiety, stress, as well as severe mental illnesses.
A deficiency in the ability to think, perceive, reason, or remember, resulting in loss of the ability to take care of one's daily living needs.
Significantly subaverage general intellectual functioning (specifically an I.Q. below 70) existing concurrently with deficits in adaptive behavior manifested during the developmental period (age 0-21).
Minimally Conscious State
A neurological state characterized by inconsistent but clearly discernible behavioral evidence of consciousness and distinguishable from coma and a vegetative state by documenting the presence of specific behavioral features not found in either of these conditions. Patients may evolve to the minimally conscious state from coma or a vegetative state after acute brain injury, or it may result from degenerative or congenital nervous system diorders. This condition is often transient but may exist as a permanent outcome.
The extent of illness, injury, or disability in a defined population. It is usually expressed in general or specific rates of incidence or prevalence.
Death. Used to describe the relation of deaths to the population in which they occur.
Multi-Stage Probability Sample
A sample drawn in successive stages. The population is first divided into primary groups (called primary sampling units or PSUs), some of which are selected (for example, with a probability proportional to their population size). Selected PSUs are then divided into clusters (e.g., of blocks), from which a sample (e.g., of households) is drawn.
Neighborhood Health Center
(Also called community health center.) An ambulatory health care program usually serving a catchment area which has scarce or nonexistent health services or a population with special health needs. These centers attempt to coordinate federal, state, and local resources in a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient population.
(Also called surplus line carriers.) Commercial insurers whose nursing home liability insurance products are not regulated by state departments of insurance. These insurers enjoy some advantages over admitted carriers. They have greater flexibility in designing and pricing products. Because they are not subject to state regulation, they can also change coverage forms and application protocols more quickly. However, they must pay an "excess and surplus lines" tax that is not levied on admitted carriers. They cannot participate in state guaranty funds, which help protect policyholders in the case of insurer insolvency.
Civil litigation is compensation due the plaintiff for intangible harms (e.g., pain and suffering).
An organization that reinvests all profits back into that organization.
The discrepancy between a sample statistic and the true population parameter that results from factors other than the sampling process. Common sources of nonsampling errors include noncoverage of certain subpopulations, questionnaire wording, and recall errors.
Number of Insureds with Buy-Up Partnership Qualified (PQ) Coverage
The number of covered lives who have elected to purchase the voluntary buy-up coverage offered by the group plan, in addition to the Core Plan coverage already provided to them.
Number of Persons Insured with Core Coverage
Indicates the number of covered lives enrolled in the core plan coverage offered by the employer.
An individual trained to care for the sick, aged, or injured. Can be defined as a professional qualified by education and authorized by law to practice nursing.
Nurse Practitioner (NP)
A registered nurse working in an expanded nursing role, usually with a focus on meeting primary health care needs. NPs conduct physical examinations, interpret laboratory results, select plans of treatment, identify medication requirements, and perform certain medical management activities for selected health conditions. Some NPs specialize in geriatric care.
Facility licensed by the state to offer residents personal care as well as skilled nursing care on a 24 hour a day basis. Provides nursing care, personal care, room and board, supervision, medication, therapies and rehabilitation. Rooms are often shared, and communal dining is common. (Licensed as nursing homes, county homes, or nursing homes/residential care facilities.)
Nursing Home Benefit Amount
The maximum amount which the policy or certificate will pay for care received in a nursing home. If the benefit is paid as weekly or monthly, the daily amount should be derived by whatever convention is most appropriate for the carrier to use. The data should be the current amount on the policy in order to account both for any voluntary increases in coverage the insured has elected or any automatic coverage increases as a result of inflation protection.
Nursing Home Benefits Paid During Reporting Period
The total amount of benefits paid during the reporting period for care in a nursing home or in a similar covered care institutional setting as defined as "nursing home" or "facility-based" care within the policy or certificate.
Nursing Home Care
Full-time care delivered in a facility designed for recovery from a hospital, treatment, or assistance with common daily activities.
Nursing Home Liability Insurance
Indemnification of nursing home providers against damages for negligent care and abuse.
Nursing Home Residents' Rights Statutes
State and federal laws to protect each nursing home resident's civil, religious and human rights.
A measure of inpatient health facility use, determined by dividing available bed days by patient days. It measures the average percentage of a hospital's beds occupied and may be institution-wide or specific for one department or service.
Occupational Health Services
Health services concerned with the physical, mental, and social well-being of an individual in relation to his or her working environment and with the adjustment of individuals to their work. The term applies to more than the safety of the workplace and includes health and job satisfaction.
Occupational Therapy (OT)
Designed to help patients improve their independence with activities of daily living through rehabilitation, exercises, and the use of assistive devices. May be covered in part by Medicare.
Captives located outside the United States. The most popular host states for offshore captives include Bermuda, Guernsey and the Cayman Islands.
Older Americans Act (OAA)
Federal legislation that specifically addresses the needs of older adults in the United States. Provides some funding for aging services (such as home-delivered meals, congregate meals, senior center, employment programs). Creates the structure of federal, state, and local agencies that oversee aging services programs. (See also Title III services.)
A representative of a public agency or a private nonprofit organization who investigates and resolves complaints made by or on behalf of older individuals who are residents of long-term care facilities.
Omnibus Budget Reconciliation Act (OBRA) of 1993
Federal legislation that limits the amount of compensation that can be paid to employees covered by long-term disability plans funded through voluntary employees' beneficiary association trusts. Any such plan with participants earning more than $150,000 could lose its tax-exempt status.
Original Coverage Effective Date as Partnership Qualified (PQ) Policy
The date that coverage first became effective under the policy or certificate help by the insured.
Other Benefit Amounts Paid During Reporting Period
The total amount of any other benefits paid during this period (e.g., caregiver training, medical devices, other ancillary benefits and services, etc.).
A patient who is receiving ambulatory care at a hospital or other facility without being admitted to the facility. Usually, it does not mean people receiving services from a physician's office or other program which also does not provide inpatient care.
(Also called comfort care.) A comprehensive approach to treating serious illness that focuses on the physical, psychological, and spiritual needs of the patient. Its goal is to achieve the best quality of life available to the patient by relieving suffering, controlling pain and symptoms, and enabling the patient to achieve maximum functional capacity. Respect for the patient's culture, beliefs, and values is an essential component.
A survey that follows a given sample of individuals over time, thus providing multiple observations on each individual in the sample.
Parents or Relatives
(Also referred to as own home). Return of the child to parental or nonlicensed/reimbursed relative's home, with ongoing assistance and/or supervision provided.
Certain types of changes to one's policy or certificate may result in the loss of Partnership-qualified status. These are defined by the rules and regulations adopted by each state for the operation of its Partnership program. This variable simply indicates whether the policy or certificate continues to retain its Partnership qualified status or if a change in coverage of some sort has resulted in the policy no longer being Partnership Qualified.
Patient Self-Determination Act (PSDA)
An amendment to the Omnibus Budget Reconciliation Act of 1990, the law became effective December 1991 requiring most United States hospitals, nursing homes, hospice programs, home health agenices, and health maintenance organizations (HMOs) to provide to adult individuals, at the time of inpatient admission or enrollment, informaiton about their rights under state laws governing advance directives (ADs), including: (1) the right to participate in and direct their own health care decisions; (2) the right to accept or refuse medical or surgical treatment; (3) the right to prepare an AD; and (4) information on the provider's policies that government the utilization of these rights. The act prohibits institutions from discriminating against a patient who does not have an AD. The PSDA further requires institutions to document patient information and provide ongoing community education on ADs.
Generally, the evaluation by practicing physicians or other professionals of the effectiveness and efficiency of services ordered or performed by other members of the profession (peers).
Permanent Vegetative State (PVS)
A vegetative state is a clinical condition of complete unawareness of the self and the environment accompanied by sleep-wake cycles with either complete or partial preservation of hypothalamic and brainstem autonomic functions. The PVS is a vegetative state present at one month after acute traumatic or nontraumatic brain injury, and present for at least one month in degenerative/metabolic disorders or developmental malformations. A PVS can be diagnosed on clinical grounds with a high degree of medical certainty in most adult and pediatric patients after careful, repeated neurologic examinations by a physician competent in neurologic function assessment and diagnosis. A PVS patient becomes permanently vegetative when the diagnosis of irreversibility can be established with a high degree of clinical certainty (i.e., when the chance of regaining consciousness is exceedingly rare).
(Also called custodial care.) Assistance with activities of daily living as well as with self-administration of medications and preparing special diets.
Personal services such as bathing and toileting, sometimes expanded to include light housekeeping furnished to an individual who is not an inpatient or a resident of a group home, assisted living facility, or long-term facility such as a hospital, nursing facility, ICF/MR, or institution for mental disease. Personal care services are those that individuals would typically accomplish themselves if they did not have a disability.
Physical Therapy (PT)
Designed to restore/improve movement and strength in people whose mobility has been impaired by injury and disease. May include exercise, massage, water therapy, and assistive devices. May be covered in part by Medicare.
Physician Assistant (PA)
(Also known as a physician extender.) A specially trained and licensed or otherwise credentialed individual who performs tasks, which might otherwise be performed by a physician, under the direction of a supervising physician.
Point of Service
A health insurance benefits program in which subscribers can select between different delivery systems (i.e., HMO, PPO and fee-for-service) when in need of medical services, rather than making the selection between delivery systems at time of open enrollment at place of employment.
Policy Benefit Type
Some policies are comprehensive in that they pay for care in all long-term care settings (nursing home, ALF, home care and others). Other policies pay just for facility-based care, and others pay for only care outside a facility. This variable indicates the type of policy with respect to the range of services it covers.
Policy Exchange to Partnership Qualified (PQ)
Some policies are PQ because they were pruchased after the effective date of the state's Partnership program and meet all the requirements in that state for being a Partnership policy. Other policies may have been purchased prior to the effective date of that state's Partnership program, but may have been granted Partnership qualified status as the result of being exhcnaged for a PQ policy. The exchange may be in the form of an amendment or rider or disclosure statement indicating that the coverage is now PQ. This variable indicates whether the policy is PQ as the result of an exchange rather than as a result of an original purchase.
Policy Issue State
The state in which the individual policy is issued. This would also be the state of residents of the insured to whom the individual policy is delivered.
The unique policy or certificate identification number assigned to each insured's coverage.
Policy Status at End of Reporting Period
Indicates whether the policy is still in force, whether the insured is in nonforteiture benefits or whether the policy has terminated during the reporting period for any number of possible reasons. The policy may no longer be in force because the insured has exhausted all their benefits, because they have died, because they have voluntarily elected to lapse coverage, because coverage has been rescinded, or because the policy was "Not Taken Out (NTO)" as defined above.
Policy/Certificate Age at which Inflation Protection Ends
The type of inflation protection that ends when the insured has received annual benefit increases for a predefined number of years. Value refers to the actual number of years which are specified in the coverage.
Post-Acute Care (PAC)
(Also called subacute care or transitional care.) Type of short-term care provided by many long-term care facilities and hospitals which may include rehabilitation services, specialized care for certain conditions (such as stroke and diabetes) and/or post-surgical care and other services associated with the transition between the hospital and home. Residents on these units often have been hospitalized recently and typically have more complicated medical needs. The goal of subacute care is to discharge residents to their homes or to a lower level of care.
A process under which admission to a health institution is reviewed in advance to determine need and appropriateness and to authorize a length of stay consistent with norms for the evaluation.
Illnesses or disability for which the insured was treated or advised within a stipulated time period before making application for a life or health insurance policy. A pre-existing condition can result in cancellation of the policy.
Preferred Provider Arrangement (PPA)
Selective contracting with a limited number of health care providers, often at reduced or pre-negotiated rates of payment.
Preferred Provider Organization (PPO)
Managed care organization that operates in a similar manner to an HMO or Medicare HMO except that this type of plan has a larger provider network and does not require members to receive approval from their primary care physician before seeing a specialist. It is also possible to use doctors outside the network, although there may be a higher co-payment.
The periodic payment (e.g., monthly, quarterly) required to keep an insurance policy in force.
The charge paid by a policyholder for insurance coverage.
Usually refers to any payment to a provider for anticipated services (such as an expectant mother paying in advance for maternity care).
Care which has the aim of preventing disease or its consequences. It includes health care programs aimed at warding off illnesses (e.g., immunizations), early detection of disease (e.g., Pap smears), and inhibiting further deterioration of the body (e.g., exercise or prophylactic surgery). Preventive medicine is also concerned with general prevention measures aimed at improving the healthfulness of the environment.
Basic or general health care focused on the point at which a patient ideally first seeks assistance from the medical care system.
Primary Sampling Unit (PSU)
Groups selected as the first stage of a multi-stage sample. For example, for the CPS sample, the United States is divided into approximately 1,900 geographic areas, or PSUs, of which 729 are selected for the sample.
Private Duty Nursing
Services, except those for mental health or substance abuse treatment, provided by registered nurses or licensed practical nurses under direction of a physician to recipients in their own homes, hospitals, or nursing facilities as specified by the state.
Probability (P value)
The likelihood that an event will occur.
Professional Liability Claims/Losses
Amounts a nursing home liability insurer is legally obligated to pay as damages and associated claims and defense expenses to a plaintiff due to a negligent act, error or omission in a nursing home provider's rendering or failure to render professional services.
Program of All-Inclusive Care for the Elderly (PACE)
A managed care plan that coordinates Medicare and Medicaid acute care and long-term care for dual eligible enrollees (those age 55 and older, living in a PACE area, and otherwise eligible for nursing home care). A capitated payment mechanism is used for PACE plan enrollees.
Any method of paying hospitals or other health programs in which amounts or rates of payment are established in advance for a defined period (usually a year).
Individual or organization that provides health care or long-term care services (e.g., doctors, hospital, physical therapists, home health aides, and more).
Provider Sponsored Organization (PSO)
Managed care organization that is similar to an HMO or Medicare HMO except that the organization is owned by the providers in that plan and these providers share the financial risk assumed by the organization.
Substitute decision maker.
Psychiatric Rehabilitation Option
An optional Medicaid service that can include (depending on state definitions) community support programs, school-based services, crisis intervention services, and outpatient psychotherapy services.
The science dealing with the protection and improvement of community health by organized community effort.
Civil litigation means monetary compensation awarded by a judge or jury which exceeds the losses suffered by the injured party in order to punish the defendant.
A collaborative behavioral health services model that brings all agencies tasked with the delivery, funding or oversight of behavioral health care services together to create a single behavioral health service delivery system.
The specific conditions for which the individual qualifies as chronically ill. This could include dependency in the required number of ADLs, cognitive impairment or both.
Quality of Care
can be defined as a measure of the degree to which delivered health services meet established professional standards and judgments of value to the consumer.
Potentially biased indirect state-level estimates can be ratio adjusted to regional totals so that the sum across states matches regional estimates. This eliminates bias at the regional level and attempts to remove bias from the state-level indirect estimator.
The practice of insurance carriers ceding risk to other firms, called re-insurance companies, in order to limit their liability exposure. Re-insurance companies essentially provide insurance to insurance companies. Instead of assessing the risk of individual policyholders, re-insurance companies assess risk on a broader scale, such as on the basis of a particular product-line (nursing home liability insurance) or a geographic region.
Registered Nurse (RN)
A nurse who has graduated from a formal program of nursing education and has been licensed by an appropriate state authority. RNs are the most highly educated of nurses with the widest scope of responsibility, including all aspects of nursing care. RNs can be graduated from one of three educational programs: two-year associate degree program, three-year hopsital diploma program, or four-year baccalaureate program.
Regulated Insurance Carrier
(Also called admitted carrier.) Commercial insurer whose nursing home liability insurance products are regulated by state departments of insurance. These carriers enjoy some advantages over nonadmitted carries. They can participate in state guaranty funds, which help protect policyholders in the case of insurer insolvency. Also, they have a marketing advantage over nonadmitted carriers because some brokers, facility providers and lenders value state oversight and participation in the guaranty fund.
The combined and coordinated use of medical, social, educational, and vocational measures for training or retaining individuals disabled by disease or injury to the highest possible level of functional ability. Several different types of rehabilitation are distinguished: vocational, social, psychological, medical, and educational.
Services designed to improve/restore a person's functioning; includes physical therapy, occupational therapy, and/or speech therapy. May be provided at home or in long-term care facilities. May be covered in part by Medicare.
The process by which health care providers receive payment for their services. Because of the nature of the health care environment, providers are often reimbursed by third parties who insure and represent patients.
The practice of insurance carriers ceding risk to other firms, called reinsurance companies, in order to limit their liability exposure. Reinsurance companies essentially provide insurance to insurance companies. Instead of assessing the risk of individual policyholders, reinsurance companies assess risk on a broader scale, such as on the basis of a particular product line (nursing home liability insurance) or a geographic region.
Remaining Lifetime ALF/Other Facility Benefits (Days)
Under a policy design with separate pools of benefits, paying on the basis of days of covered services, the total number of days of care remaining available to the insured in the ALF Benefit Pool.
Remaining Lifetime ALF/Other Facility Benefits (Dollars)
Under a policy design with separate pools of benefits, paying on the basis of dollars for covered services, the total dollar amount of care remaining available to the insured in the ALF Benefit Pool.
Remaining Lifetime Benefits
Under a policy design with a single pool of dollars as the Lifetime Maximum, the total dollar amount of benefits remaining available to the insured in the Lifetime Maximum at the end of the reporting period.
Remaining Lifetime Home Health Care Benefits (Days)
Under a policy design with separate pools of benefits, paying on the basis of days of covered services, the total number of days of care remaining available to the insured in the Home Health Care Benefit Pool.
Remaining Lifetime Home Health Care Benefits (Dollars)
Under a policy design with separate pools of benefits, paying on the basis of dollars for covered services, the total dollar amount of care remaining available to the insured in the Home Health Care Benefit Pool.
Remaining Lifetime Nursing Home Benefits (Days)
Under a policy design with separate pools of benefits, paying on the basis of days of covered services, the total number of days of care remaining available to the insured in the Nursing Home Benefit Pool.
Remaining Lifetime Nursing Home Benefits (Dollars)
Under a policy design with separate pools of benefits, paying on the basis of dollars for covered services, the total dollar amount of care remaining available to the insured in the Nursing Home Benefit Pool.
A captive, usually formed by an insurance company, broker or captive manager, and rented out to users (in this case nursing home providers) who avoid the cost of funding their own captive. The user provides some form of collateral so that the rent-a-captive is not at risk from any underwriting loss suffered by the user.
The date on which the Registry File is submitted.
The period for which reporting on each file is required. File 1 -- the Registry File is filed semi-annually and is required to cover the period January 1 through June 30 and July 1 through December 31. Both File 2 -- the Claimant File, and File 4 -- the Claimant File for Employer-Paid Core/Buy-Up Plans, are filed quarterly and is required to cover the period January 1 through March 31, April 1 through June 30, July 1 through September 30, and October 1 through December 31. File 3 -- the Registry File for Employer-Paid Core Only & Care and Buy-Up Plans will be reported annually for the reporting period January 1 through December 31.
The provision of room, board and personal care. Residential care falls between the nursing care delivered in skilled and intermediate care facilities and the assistance provided through social services. It can be broadly defined as the provision of 24-hour supervision of individuals who, because of old age or impairments, necessarily need assistance with the activities of daily living.
Although room and board services provided in residential care facilities is not covered by Medicaid, other components of residential care--for example, personal care, 24-hour services, and chore services--can be covered. Residential care includes group, family or individual home residential care; cluster residential care; and theapeutic residential care services, assisted living, supported living, and night supervision.
The diagnostic evaluation, management, and treatment of the care of patients with deficiences and abnormalities in the cardiopulmonary (heart-lung) system.
Service in which trained professionals or volunteers come into the home to provide short-term care (from a few hours to a few days) for an older person to allow caregivers some time away from their caregiving role.
Enrollee who receives limited Medicaid coverage, inlcuding unqualified aliens only eligible for emergency hospital benefits, duals receiving only Medicare cost-sharing benefits, and people eligible for only family-planning services.
Service in which trained professionals or volunteers come into the home to provide short-term care (from a few hours to a few days) for an older person to allow caregivers some time away from their caregiving role.
Risk Management Program
A structured approach to purposefully limit liability risk. They include systematic efforts to improve and maintain high standards for care quality, but can also include additional management techniques to minimize liability exposure, such as improving written documentation. They are often formalized within the management structure of nursing home providers in the form of Risk Management Committees, and/or a designated Director of Risk Management along with formal Risk Management plans that are implemented and monitored by senior management.
Risk Retention Group (RRG)
An insurance company that is owned by its members. The members of an RRG come from the same industry. For instance, nursing home providers can form an RRG in order to obtain nursing home liability coverage.
The discrepancy between a sample statistic and the true population parameter that results from the sampling process. Sampling error can have a random component (sampling variance) and fixed component (bias).
Random error (discrepancy between a sample statistic and the true population parameter) that arises because a random process is used to select the survey sample. If the sampling process is repeated several times, a different group of respondents would be selected each time and the sample distributions of answers to the survey questions would be somewhat different in each sample.
The use of quick procedures to differentiate apparently well persons who have a disease or a high risk of disease from those who probably do not have the disease.
Services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologist, urologists, dermatologists).
(Also called training school, reformatory, detention center, jail, or secure hospital.) Twenty-four hour residential care facility of any size, designed and operated to ensure that all entrances and exits are under the exclusive control of the staff, whether or not the person being detained has freedom of movement within the facility perimeters.
The generalized characterization of progressive decline in mental functioning as a condition of the aging process. Within geriatric medicine, this term has limited meaning and is often substituted for the diagnosis of senile dementia and/or senile psychosis.
Provides a variety of on-site programs for older adults including recreation, socialization, congregate meals, and some health services. Usually a good source of information about area programs and services.
Seriously Emotionally Disturbed
A condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree, which adversely affects daily activities: an inability to learn which cannot be explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal relationships with peers or teachers. Inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness of depression or a tendency to develop physical symptoms of fears associated with personal or school problems. The term includes persons who are schizophrenic or autistic. The term does not include persons who are socially maladjusted, unless it is determined that they are also seriously emotionally disturbed.
(Also called care plan or treatment plan.) Written document which outlines the types and frequency of the long-term care services that a consumer receives. It may include treatment goals for him or her for a specified time period.
An agreement reached between the legal counsel of the plaintiff and the defendant that terminates a civil litigation before a verdict is reached by the court.
Severity of Illness
A risk prediction system to correlate the "seriousness" of a disease in a particular patient with the statistically "expected" outcome (e.g., mortality, morbidity, efficiency of care).
The state in which the group policy is sitused, as specified on the group policy form.
"Higher level" of care (such as injections, catheterizations, and dressing changes) provided by trained medical professionals, including nurses, doctors, and physical therapist.
Skilled Nursing Care
Daily nursing and rehabilitative care that can be performed only by or under the supervision of, skilled medical personnel.
Skilled Nursing Facility (SNF)
Facility that is certified by Medicare to provide 24-hour nursing care and rehabilitation services in addition to other medical services. (See also nursing home.)
Social Security Disability Insurance (SSDI)
A system of federally provided payments to eligible workers (and, in some cases, their families) when they are unable to continue working because of a disability. Benefits begin with the sixth full month of disability and continue until the individual is capable of substantial gainful activity.
An individual must have an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months. To meet this definition, an individual's impairment or combination of impairments must be so severe that he or she is unable to do past work, but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful activity which exists in the national economy. SSDI benefits are also paid to dependents (age 18-64) of retired, deceased or disabled workers provided they were disabled in childhood, and widows/widowers aged 50 or over who were married to SSDI beneficiaries. There are different rules for determining disability for those who are statutorily blind (i.e. with central visual, acuity of 20/200 or less in the better eye with the use of correcting lens), widow/widowers, and surviving divorced wives.
Social Services Block Grant (SSBG) Services
(Formerly known as Title XX services.) Grants given to states under the Social Security Act which fund limited amounts of social services for people of all ages (including some in-home services, abuse prevention services, and more).
There is no Federal statutory definition. States set their own criteria for determining disability.
Social Health Maintenance Organization (SHMO)
A managed system of health and long-term care services geared toward an elderly client population. Under this model, a single provider entity assumes responsibility for a full range of acute inpatient, ambulatory, rehabilitative, extended home health and personal care services under a fixed budget which is determined prospectively. Elderly people who reside in the target service area are voluntarily enrolled. Once enrolled, individuals are obligated to receive all SHMO covered services through SHMO providers, similar to the operation of a medical model health maintenance organization (HMO).
Special Care Units
Long-term care facility units with services specifically for persons with Alzheimer's Disease, dementia, head injuries, or other disorders.
Designed to help restore speech through exercises. May be covered by Medicare.
A series of months during which a person received Medicaid-covered nursing home services for at least one day of each month and received no such services during the month preceding and following the series.
Medicaid financial eligibility requirments are strict, and may require beneficiaries to spend down/use up assets or income until they reach the eligibility level.
Federal regulations preserve some income and assets for the spouse of a nursing home resident whose stay is covered by Medicaid.
Common measure of dispersion or spread of data about the mean.
The most commonly used measure of the precision of an estimate. A gauge of how close an estimate is likely to be to the population value in the absence of any bias.
State Unit on Aging
Authorized by the Older Americans Act. Each state has an office at the state level which administers the plan for service to the aged and coordinates programs for the aged with other state offices.
Strata (state stratification)
Stratification is a sampling method whereby the population is divided into subgroups (or "strata"), based on characteristics believed to be correlated with the survey variables of greatest interest, and a sample is then selected from each subgroup. Stratification produces survey estimates of a desired precision within the chosen subgroups, which cannot be assured with an unstratified design. State stratified samples will allow for unbiased state-level estimates and estimates of precision.
(Also called post-acute care or transitional care.) Type of short-term care provided by many long-term care facilities and hospitals which may include rehabilitation services, specialized care for certain conditions (such as stroke and diabetes) and/or post-surgical care and other services associated with the transition between the hospital and home. Residents on these units often have been hospitalized recently and typically have more complicated medical needs. The goal of subacute care is to discharge residents to their homes or to a lower level of care.
Supplemental Security Income (SSI)
A program of support for low-income aged, blind and disabled persons, established by Title XVI of the Social Security Act. SSI replaced state welfare programs for the aged, blind and disabled in 1972, with a federally administered program, paying a monthly basic benefit nationwide of $284.30 for an individual and $426.40 for a couple in 1983. States may supplement this basic benefit amount.
Individuals can qualify as disabled or blind. For disability, an individual must have an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months. For blindness, an individual must be statutorily blind, that is, having central visual, acuity of 20/200 or less in the better eye with the use of correcting lens. Adults: To meet this definition, an individual's impairment or combination of impairments must be so severe that he or she is unable to do past work, but cannot, considering age, education, and work experience, engage in any other kind of substantial gainful activity which exists in the national economy. Children: A child under age 18 will be considered disabled for purposes of eligibility if he suffers from any medically determinable physical or mental impairment of "comparable severity" to that which would make an adult disabled.
Groups of people who share a common bond (e.g., caregivers) who come together on a regular basis to share problems and experiences. May be sponsored by social service agencies, senior centers, religious organizations, as well as organizations such as the Alzheimer's Association.
(Also called proxy by default.) A person who, by default, become the proxy decision maker for an individual who has no appointed agent.
An investigation in which information is systematically collected.
A class of model-dependent estimates generally formed by dividing the population into subgroups (e.g., by age/race/sex) and assuming that national estimates for each subgroup can be applied to the local populations.
A comprehensive form of policy research that examines the technical, economic, and social consequences of technology applications.
Termination of FPO Option
Indicates when the FPO offers end. For some policies they may continue for the life of the policy even while the insured is on claim; for others they may end when the individual is on claim or within a specified time period of having received benefits. The FPO offers may end at a defined age or when the insured has declined a certain number of increase offers.
Title III Services
Services provided to individuals age 60 and older which are funded under Title III of the Older Americans Act. Include: congregate and home-delivered meals, supportive services (e.g., transportation, information and referral, legal assistance, and more), in-home services (e.g., homemaker services, personal care, chore services, and more), and health promotion/disease prevention services (e.g., health screenings, exercise programs, and more). (See also Older Americans Act.)
Title XIX (Medicaid)
federal and state-funded program of medical assistance to low-income individuals of all ages. There are income eligibility requirements for Medicaid.
Title XVIII (Medicare)
Federal health insurance program for persons age 65 and over (and certain disabled persons under age 65). Consists of 2 parts: Part A (hospital insurance) and Part B (optional medical insurance which covers physicians' services and outpatient care in part and which requires beneficiaries to pay a monthly premium).
Title XX Services
(Now known as Social Services Block Grant services.) Grants given to states under the Social Security Act which fund limited amounts of social services for people of all ages (including some in-home services, abuse prevention services, and more).
A movement intended to curb litigation and damages in the civil justice system. With respect to nursing home liability insurance, many states have enacted tort reform through legislation and it has changed the legal framework under which residents and/or family members can seek damages for negligent or abusive care practices. States also placed limits on the amount of damages that could be awarded to plaintiffs and/or their family members, particularly noneconomic damages for pain and suffering.
Total Cash Benefits Paid During Reporting Period
The total dollar amount of benefits paid on a cash basis during the reporting period.
Total Lifetime Benefits Paid to Date
Indicates the total amount of benefits paid under the certificate to date as of the end of the reporting period.
(Also called subacute care or post-acute care.) Type of short-term care provided by many long-term care facilities and hospitals which may include rehabilitation services, specialized care for certain conditions (such as stroke and diabetes) and/or post-surgical care and other services associated with the transition between the hospital and home. Residents on these units often have been hospitalized recently and typically have more complicated medical needs. The goal of subacute care is to discharge residents to their homes or to a lower level of care.
(Also called escort services.) Provides transportation for older adults to services and appointments. May use bus, taxi, volunteer drivers, or van services that can accommodate wheelchairs and persons with other special needs.
(Also called care plan or service plan.) Written document which outlines the types and frequency of the long-term care services that a consumer receives. It may include treatment goals for him or her for a specified time period.
Service provided by physicians and hospitals for which no payment is received from the patient or from third party payers.
People with public or private insurance policies that do not cover all necessary medical services, resulting in out-of-pocket expenses that exceed their ability to pay.
The process by which an insurer assesses the risk of insuring a particular applicant for coverage. Risk retention groups also underwrite by assessing the risk of accepting a prospective member.
With respect to the provision of accommodation for an individual with a disability under the Americans with Disabilities Act--significant difficulty or expense, considered in light of the employer's financial resources, facilities, workforce, and business operations.
Veterans' Disability Compensation Program
An individual must have a partial or total impairment by injury or disease incurred or aggravated during military service. A Veterans' Affairs (VA) rating board employs criteria developed by the VA to rate the extent of a disability.
Veterans' Disability Pension Program
An individual must have an injury or disease sustained outside of military service regarding a veteran permanently and totally impaired. Impairment is determined based on the veteran's ability to function at work and at home.
Veterans' Health Services Programs
Veterans' Affairs (VA) hospitals are required to provide care to Class A veterans defined as those: rated as "service-connected; retired from active duty for a disability incurred or aggravated while in military service; in receipt of a VA pension; eligible for Medicaid; a former POW; in need of care for a condition that is possibly related to exposure to dioxin or other toxic substance; in need of care for a condition possibly related to exposure to radiation from nuclear tests or in the American occupation of Japan; or has an income below $16,466 with no dependents; or $19,759 with one dependent (with $1,055 added for each additional dependent). VA hospitals provide care on a space-available basis to persons in Category B veterans, those whose disabilities are not service-connected and have incomes above $16,466 but below $21,954. (Category C veterans have higher incomes and must pay a copayment.)
Visiting Nurse Association (VNA)
A voluntary health agency which provides nursing and other services in the home. Basic services include health supervision, education and counseling; beside care; and the carrying out of physicians' orders. Personnel include nurses and home health aides who are trained for specific tasks of personal bedside care. These agencies had their origin in the visiting or district nursing provided to sick poor in their homes by voluntary agencies.
Statistics relating to births (natality), deaths (mortality), marriages, health, and disease (morbidity).
A dynamic state of physical, mental, and social well-being; a way of life which equips the individual to realize the full potential of his or her capabilities and to overcome and compensate for weaknesses; a lifestyle which recognizes the importance of nutrition, physical fitness, stress reduction, and self-responsibility.
Forgoing or discontinuing life-sustaining measures.
Workers' Compensation Program
State-mandated system under which employers assume the cost of medical treatment and wage losses for employees who suffer job-related illnesses or injuries, regardless of who is at fault. In return, employees are generally prohibited from suing employers, even if the disabling event was due to employer negligence. U.S. government employees, harbor workers, and railroad workers are not covered by state workers' compensation laws, but instead by various federally administered laws.
None at this time.
None at this time.
None at this time.
Last revised: January 23, 2012
Error processing SSI file